Patient nutrition assessment form

What is your usual diet like?

Do you have any allergies or food intolerances?

Do you have any chronic medical conditions that require a special diet?

Do you take any medications that could affect your appetite or nutrition?

Are you able to chew and swallow normally?

Do you have any difficulty preparing meals or eating out?

Do you have any trouble shopping for groceries or cooking meals?

Are you at a healthy weight?

Are you trying to lose, gain, or maintain your weight?

Do you feel like you are getting enough fruits, vegetables, and other healthy foods in your diet?

Do you eat fast food or processed foods often?

Do you drink alcohol, smoke cigarettes, or use other drugs?

Do you have any other concerns about your diet or nutrition? If yes, let us know.