Nutrition Assessment Form

The Nutrition Assessment Form is a tool used by healthcare professionals to assess an individual's nutritional status. The form should include questions about the individual's medical history, dietary intake, and physical examination. The form is used to determine whether the individual is at risk for malnutrition or if they have any existing nutritional deficiencies.

Time to complete

3 minutes

Eligibility

Anyone who is interested in learning more about their diet's nutritional content can complete this nutrition assessment form.

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Questions for Nutrition Assessment Form

1.

What is your name?

The answer should be a text input.
2.

Age

The answer should be a single choice:
  1. Under 18
  2. 18-24 years old
  3. 25-34 years old
  4. 35-44 years old
  5. 45-54 years old
  6. Over 55
3.

Gender

The answer should be a single choice:
  1. Male
  2. Female
  3. Other
  4. Prefer not to say
4.

Phone Number

The answer should be a phone number.
5.

Address

The answer should be a text input.
6.

Nationality

The answer should be a country.
7.

How many calories do you eat in a day?

The answer should be a text input.
8.

What is your daily intake of fat?

The answer should be a text input.
9.

What is your daily intake of protein?

The answer should be a text input.
10.

What is your daily intake of fiber?

The answer should be a text input.
11.

How many meals do you eat per day?

The answer should be a text input.
12.

How often do you eat fast food, take-out, or processed foods?

The answer should be a text input.
13.

What is your diet like?

The answer should be a single choice:
  1. I eat a lot of fruits and vegetables
  2. I eat mostly junk food
  3. I eat a lot of meat
  4. I eat a lot of dairies
  5. I eat a lot of carbohydrates
  6. I have a balanced diet
14.

What is your daily water intake like?

The answer should be a text input.
15.

Do you eat breakfast every day?

The answer should be a text input.
16.

Do you skip meals?

The answer should be a text input.
17.

Do you take any vitamin or mineral supplements?

The answer should be a single choice:
  1. Yes
  2. No
18.

Do you have any food allergies?

The answer should be a text input.
19.

Do you have any medical conditions?

The answer should be a text input.

Similar Ideas

  • Patient Nutrition Assessment Form
  • Nutrition Risk Assessment Form
  • Child Nutrition Assessment Form

Here are some FAQs and additional information
on
Nutrition Assessment Form

What is the purpose of nutrition assessment?

The purpose of the Nutrition Assessment Form is to collect data about an individual's dietary intake and eating habits. This information can be used to assess an individual's nutritional status and to develop a plan to improve their diet.

Why is a Nutrition Assessment Form necessary?

A Nutrition Assessment Form is necessary in order to determine an individual’s specific dietary needs. This information is important in order to develop a personalized diet plan that meets the individual’s needs.

How often should I update my Nutrition Assessment Form?

The Nutrition Assessment Form should be updated every three months.

What information should I include in my nutrition assessment?

When completing a nutrition assessment, you should include information about your current eating habits, as well as any changes you have made to your diet in the past year. You should also include information about your weight, height, and any medical conditions that may impact your diet.

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