ATNG Nutrition Pre-Assessment Form

Name* This field is required.

First Name

Last Name

Age* This field is required.

Age in Years

Height* This field is required.Please state how tall you are.

Feet and inches

Weight* This field is required.Please state your most recent weight.

Weight in pounds

Weight Assessment at our Office* This field is required.Are you comfortable having your body weight assessed at our office?

YESNO

Gender* This field is required.

Male

Female

Other

I prefer not to answer this question

Is weight loss one of your reasons you are seeking nutritional counseling?* This field is required.

YESNO

If you are interested in reducing body weight, please select which approach you feel suits your goals

I am not sure what will be the best approach to promote my weight loss goals

I want a strict meal plan that promotes a rapid weight loss

I do not want a strict meal plan; I prefer to make small changes over time that will get me to my goals and produce a sustainable result

I am interested in a very specific diet that I need help with and I will talk to my dietitian about this

I need another approach that is not listed here

Please explain your reasons for seeking nutritional counseling. This may include losing weight, managing blood sugar, managing a digestive or gastrointestinal issue, or simply implementing a healthy diet to prevent problems. You may have other reasons. Your answer will help us to identify your specific needs for nutritional counseling.* This field is required.

MedicationPlease list medications you are currently taking. Specify the dose of each medication if you can. Nutritional supplements are addressed in the next question.

SupplementationPlease list Vitamin and/ or Herbal supplements you are currently taking. Specify the dose of each supplement if you know what it is, and also state how often you take the supplement.

Please indicate if you have any of the following conditions:* This field is required.YOUR HEALTH HISTORY

Diabetes

High Cholesterol

Heart Disease

Stroke

Pre-diabetes

PCOS

Gout

High Blood Pressure

Anemia

GERD

Food Allergy

Food Intolerance

Irritable Bowel Syndrome

Constipation

Autoimmune Disease

Hypothyroidism

Cancer

Arthritis

SIBO

Inflammatory Bowel Disease

Obesity

Overweight

Eating Disorder

Fatty Liver Disease

Osteoporosis

Osteopenia

Sleep Apnea

COPD

Other

None

Other conditionsPlease list any other condition you may have that you would like your nutritionist to know about.

Please indicate if anybody in your immediate family has had any of the following conditions.* This field is required.FAMILY HISTORY

Diabetes

Heart Disease

Pre-diabetes

High Cholesterol

Stroke

High Blood Pressure

Cancer

Arthritis

Obesity

Osteoporosis

Hypothyroidism

Other

I do not know my family history

Weight History * This field is required.Please provide a brief history regarding body weight. You may include information regarding your highest and lowest adult weight, any previous weight loss methods, or anything else you feel may be helpful such as unintentional weight changes.

Sleep Assessment* This field is required.Sleep patterns can affect your health and your nutritional intake.

How many hours of sleep do you get per night on average?

Do you fall asleep easily when you go to bed at night?

Do you wake up during the night?

Do you wake up feeling rested?

Please list anything other information you feel is relevant to your sleeping habits.

Energy Levels* This field is required.Please describe your energy levels during the day. Are there any times in the day when you feel a slump in energy levels or feel particularly tired?

Tobacco / Nicotine Use* This field is required.

Please indicate if you use Tobacco or Nicotine Products

Tobacco / Nicotine use/ continued...How many days, months or years since you last used tobacco or nicotine products?

Physical Activity* This field is required.Do you participate in any formal exercise apart from the activity you get from your daily routine

Physical Activity Assessment* This field is required.This section is used to identify your usual weekly activity level

Please list here the type of exercise you like to do.

How many times per week do you engage in planned exercise

Please state how much time you spend exercising

Alcohol Consumption

Do you consume alcoholic beverages, such as wine, beer or liquor?

Please indicate how many times a week you usually consume alcohol .

How many drinks do you consume per drinking occasion?

Please list the types of drinks you prefer, e.g. Wine, Beer, Cocktails, Bourbon, etc.

STRESS ASSESSMENT. Stress can affect your health , appetite, and weight. Please describe your typical stress level on a scale of 0 to 10 in the box that follows next, with 0 indicating no stress and 10 indicating severely stressed.STRESS ASSESSMENT SCALE

Stress Level Assessment* This field is required.

Please indicate your level of stress on a scale of 0 to 10

Do you think Stress affects your eating/sleeping/exercise habits, if so describe how stress affects you.

How often do you feel stressed?

How do you manage your stress?

For Women: Are you postmenopausal?

YESNO

For Women : Are you pregnant or nursing?

YESNO

For Women: Questions related to menstruation

Are your menstrual cycles regular?

Do you suffer from premenstrual symptoms?

Describe your pre-menstrual or menstrual symptoms.

Do you use hormone therapy or contraceptive medication?

Vegan Diet?* This field is required.Are you following a strict vegetarian diet that excludes all animal food products?

YESNO

Beverages* This field is required.Please check all the beverages that you usually consume.

Regular Coffee

Energy Drinks

Decaffeinated Coffee

Regular Soda

Hot Tea

Diet Soda

Sweet Tea

Herbal Tea

Unsweet Tea

Fruit Juice

Sport Drinks, like Gatorade

Seltzer Water, unsweetened

Water

Hot Chocolate

Other

Do you usually eat Fruit?* This field is required.

YESNO

Fruit* This field is required.Please check all that apply to you

Fresh Fruit, for example Apples, Bananas, Oranges, Strawberries, Blueberries, etc.

Fruit Juice

Dried Fruit, such as Dried Mango, Raisins, Dried Apples, Dried Prunes, Dates, etc.

Frozen Fruit

Canned Fruit

Other

None

Do you Eat Vegetables and/or Salads* This field is required.

YESNO

Please select all the forms of vegetables you usually eat* This field is required.

Salads

Fresh Vegetables

Canned Vegetables

Frozen Vegetables

Vegetable Juice

Lentils

Beans such as Black Beans and Pinto beans

Lima Beans

Chickpeas OR Garbanzo Beans

Hummus

Edamame Beans

Other

None

Milk and Dairy Products* This field is required.Do you use regular Milk and Dairy Products such as cheese and yogurt as part of your usual diet

YESNO

Milk and Dairy Products* This field is required.Please check all that apply to you

Regular Milk, Whole, 2% , 1% , Fat Free or Skim

Cheese, e.g. Cheddar, Swiss, Havati and other hard cheeses.

Yogurt, fruit or plain

Cottage Cheese

Coffee Creamer

Cream OR Half and Half

Ice-cream or Frozen Yogurt

Other

None

Red Meat, such as Beef, Pork, Bison* This field is required.Do you eat read meat products?

YESNO

Red Meat* This field is required.Please select all the products you eat as part of your usual eating a habits

Beef

Lamb

Pork

Sausages

Deli Meat

Bison

Bacon

Venison

Other

None

Poultry, such as Chicken, Turkey or Duck* This field is required.

YESNO

Chicken, Turkey or Duck* This field is required.Please check all that apply to you

Chicken

Duck

Turkey

Deli Meat

Chicken Sausage

Turkey Bacon

Other

None

Eggs* This field is required.Do you eat Eggs

YESNO

Fish and Shell Fish* This field is required.Do you usually eat fish and/or shellfish?

YESNO

Fish and Shellfish* This field is required.Please select all the items you usually eat

White Fish such as Tilapia and Cod

Oily Fish such as Salmon

Tuna

Shrimp

Crab

Scallops

Oysters/ Mussels

Other

None

Do you eat nuts or nut butters?* This field is required.

YESNO

Nut and Nut Butters* This field is required.Please check all the foods you usually eat

Nut Butter, for example Peanut Butter or Almond Butter

Nuts, for example Almonds, Cashews, Walnuts

Seeds, for example Sunflower Seeds, Chia seeds, Pumpkin seeds, etc.

Other

None

Starch OR Carbohydrate-containing foods* This field is required.Please check all the foods that you usually eat

Bread

Rice

Crackers

Quinoa

Pasta

Corn

Grits

Oatmeal

Granola

Breakfast Cereal

Bagels/ Bread Buns

English Muffins

Chips

Pretzels

Potatoes

Waffles

Sweet Potatoes

Tortillas

Other

None

Fats and Oils* This field is required.Please check all the foods that you usually use

Olive Oil

Margarine

Canola OIl

Coconut Oil

Vegetable Oil

Butter

Salad Dressing

Mayonnaise

Avocado

Olives

Other

None

Miscellaneous* This field is required.Please check all the foods that you usually use

Sugar

Cookies/ Cakes

Artificial Sweeteners

Candy

Honey/ Syrup/Jam

Chocolate

Soup

Tofu/ Tempeh

Pizza

Other

Dietary Restrictions / InclusionsPlease list dietary restrictions that apply to you.

Please describe any cultural or religious restrictions regarding food.

Please list any food allergies or intolerances you have.

Please list any other foods that you do not eat or do not like.

Please list any food you feel you must have included into your meal plan.

Do you live alone OR whom do you live with?* This field is required.This question is asked so that we can understand more about how meals are prepared and shared in your home and the logistics involved with grocery shopping, etc.

TrackingPlease let us know more about the tracking Tools/ Apps you have used to monitor your food intake or activity

Describe the methods used here

Meal Pattern* This field is required.Please check all of the boxes that apply to you

I usually eat Breakfast

I do not usually eat Breakfast

I usually eat Lunch

I do not usually eat Lunch

I usually eat out at Lunchtime

I make or pack my Lunch each day

I tend to snack between meals

I do not snack between meals

I usually eat Dinner

I do not usually eat Dinner

I snack after Dinner

I tend to graze and do not eat structured meals

Meals* This field is required.Tell us more about how you get the meals you usually eat.

How often do you eat foods that have not been prepared at home?

How often do you eat fast food?

How often do you eat out at restaurants?

Do you know how to cook; and do you enjoy cooking?

Where do you usually do your grocery shopping?