NUTRITIONAL ASSESSMENT
1. Patient Details
Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
Date
Assessment Date
*
/
Day
/
Month
Year
Date
2. General Nutrition & Diet Questions
Cooking & Basic Diet
Do you like to cook?
*
Yes
No
Do you eat fruit?
*
Yes
No
How many serves of fruit daily?
*
Top 3 favourite fruits
*
Apple
Banana
Orange
Grapes
Strawberry
Watermelon
Pineapple
Mango
Blueberry
Other
How many times per week do you eat takeaway food?
*
Grains / Cereals
Do you eat grains/cereals?
*
Yes
No
How many serves of grains/cereals daily?
*
Tick any grains/cereals that apply
*
Rice
Pasta
Quinoa
Bread
Cereals
Other
Food Noise
How do you rate your food noise?
*
3. Caffeine Intake
Do you use caffeine products?
*
Yes
No
How many serves of caffeine daily?
*
Tick any caffeine products that apply
*
Tea
Coffee
Cola type drinks
Chocolate
Other
4. Eating Disorder History
Have you ever had any eating disorder behaviours?
*
Yes
No
Tick any eating disorder behaviours that apply
*
Overeating
Restrictive eating
Laxative use
Bingeing
Purging
Excessive exercise
5. Hydration / Water Intake
Do you drink water?
*
Yes
No
How much water do you consume daily? (L)
*
Do you add electrolytes to water?
*
Yes
No
6. Food Intolerances
Do you have any food intolerances or food reactions?
*
Yes
No
Comments
7. Alcohol Intake
Do you drink alcohol?
*
Yes
No
How many days per week do you drink alcohol?
*
Favourite types of alcohol
*
Beer
Wine
Spirits
Cocktails
Other
8. Sugar Intake
Do you eat processed sugar?
*
Yes
No
How many days per week do you eat processed sugar?
*
Favourite types of sugary foods
*
Chocolate
Candy
Pastries
Ice cream
Other
9. Salty Snacks
Do you eat processed salty snacks?
*
Yes
No
How many days per week do you eat processed salty snacks?
*
Favourite salty snacks
*
Chips
Pretzels
Popcorn
Nuts
Other
10. Typical Meal Patterns
Typical breakfast
*
Typical lunch
*
Typical dinner
*
Typical snacks / dessert
*
Submit
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