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Ailments

Please list your primary nutrition concern at this time.

Cardiovascular - For the following list, please check every condition that you have ever had. Please also give any details about each condition that you check.
Heart DiseaseCongestive heart failureHigh CholesterolHigh Blood PressureStrokeOther

Endocrine/metabolism - For the following list, please check every condition that you have ever had. Please also give any details about each condition that you check.
DiabetesDiabetes, gestationalMetabolic syndromeObesityOverweightOther

Excretory - For the following list, please check every condition that you have ever had. Please also give any details about each condition that you check.
Acute Kidney DiseaseChronic Kidney DiseaseOther

GI Disorder - For the following list, please check every condition that you have ever had. Please also give any details about each condition that you check.
Crohn's diseaseDiverticulitis/osisInflammatory bowel diseaseLactose intoleranceLiver diseasePancreatic diseaseOther

Gynecological
AmenorrheaLactatingBreast InfectionPerimenopausal/postmenopausalCurrently Pregnant (enter how many weeks)Pregnant with single fetusPregnant with multiple fetusesOther

Hematology/oncology - For the following list, please check every condition that you have ever had. Please also give any details about each condition that you check.
AnemiaCancerOther

Immune - For the following list, please check every condition that you have ever had. Please also give any details about each condition that you check.
AIDS/HIVFood allergiesOther

Musculo-skeletal - For the following list, please check every condition that you have ever had. Please also give any details about each condition that you check.
OsteoporosisOther

Psychological - For the following list, please check every condition that you have ever had. Please also give any details about each condition that you check.
AlcoholismDementia/Alzheimer'sDepressionEating disorderPsychosisOther

Respiratory - For the following list, please check every condition that you have ever had. Please also give any details about each condition that you check.
COPDOther

Other - If there are any other conditions that you have ever had that you did not list above, please list them here and give any details about the conditions.


Misc question holding group


Have you had an eye exam in the past 12 months?
NoYes     Date

Have you had a dental exam in the past 6 months?
NoYes     Date

Have you had a flu vaccine in the past 6 months?
NoYes     Date

Have you ever had a pneumonia vaccine?
NoYes     Date


Client History(CH)


On a scale of 1-10 how would you describe your current mobility status?
Mobility is your ability to move around with ease and without physical restrictions or limitations.

Very limited23456789Complete Mobility

Who is primarily responsible for food selection and preparation on your household?
SelfParent/guardianSpouseRoommateSiblingFriendOther

Do you use tobacco
Yes     Type -- CigarettesCigarsPipeChewSnuffSnus     Daily Use --
No
Quit     Quit Date

Have you had any surgeries that effect your nutrition or exercise status?
YesNo

Please provide details about your surgeries and include the dates of the surgeries


Food History


Estimate the number of calories you eat per day.

How many of each of the following do you eat each day?
Meals

Snacks

Do you drink alcohol?
Yes     When -- RegularlySocially     Drinks per week --
No
Quit     Quit Date


Eating Habits

For each of the following food areas, tell us how often you eat the food or drink. If you eat or drink it less than once a day, check "Servings Per Week" and enter the number of times you eat or drink it each week. If you eat or drink it one or more times a day, check "Servings Per Day" and enter the number of times you eat or drink it each day. If you rarely or never eat or drink it, check "Never consume this".


Milk, cheese, yogurt, other dairy foods:
Example serving of dairy: 1 cup milk, 6oz yogurt, 1 slice cheese

Servings Per WeekServings Per DayNever Consume this. Please explain:

Breads, cereals, grains (pasta, rice etc.):
Example serving of grains: One 1/2 cup of cooked rice, pasta, or snacks such as chips or pretzels -- a rounded handful, or a tennis ball

Servings Per WeekServings Per DayNever Consume this. Please explain:

Meat, fish, poultry, eggs, dried peas, beans, lentils:
Example serving of meat or poultry -- the palm of your hand or a deck of cards
Example serving of fish -- a checkbook

Servings Per WeekServings Per DayNever Consume this. Please explain:

Vegetables and vegetable juices:
Example serving of vegetables: 1 cup of chopped raw fruits or vegetables -- a woman's fist or a baseball, or 2 cups leafy greens --2 handfuls
Example serving of starchy vegetables: One medium baked potato, 1/2 cup mashed potatoes/corn/peas/beans -- a computer mouse

Servings Per WeekServings Per DayNever Consume this. Please explain:

Fruit and fruit juices:
Example serving of fruit: One medium apple or orange -- a tennis ball or One-quarter cup of dried fruit or nuts -- a golf ball or small handful

Servings Per WeekServings Per DayNever Consume this. Please explain:

Fats: butter, oil, margarine, salad dressings:
Example serving of fat/oil: Teaspoon of oil/butter--tip of thumb, 1/4 cup nuts--small handful, Two tablespoons of peanut butter -- a ping-pong ball or thumb

Servings Per WeekServings Per DayNever Consume this. Please explain:

Desserts (cakes, candy, ice cream etc.):
Servings Per WeekServings Per DayNever Consume this. Please explain:

Beverages (coffee, tea, soda etc.):
Servings Per WeekServings Per DayNever Consume this. Please explain:

Water:
Servings Per WeekServings Per DayNever Consume this. Please explain:


Diet and Nutrition History (FH)


Have you ever been counseled by a dietitian or have you ever attended a nutrition class?
YesNo

Please describe when you were counseled by a dietitian or attended a nutrition class, and also what type of counseling or class it was.

Have you changed your diet to avoid any foods due to food allergies?
YesNo

Please list any allergies that you have or foods that you avoided.

Have you changed your diet to avoid any foods due to food intolerances?
YesNo

Please list any food intolerances that you have or foods that you avoided.

Do you have any cultural food preferences we should be aware of?
YesNo

Please describe any cultural food preferences we should be aware of.


Diet and Nutrition Habits (FH)


Where do you eat the majority of your meals?
HomeWorkSchoolRestaurantCar


Medication and Complementary/alternative Medicine Use


Are you currently taking any prescription medications?
YesNo

What prescription medications are you currently taking?

Are you currently taking any over the counter medications?
YesNo

What over the counter medications are you currently taking?

Are you currently taking any other supplements? (i.e. garlic, elderberry, gingko, etc…)
YesNo

What other supplements are you taking? (i.e. garlic, elderberry, gingko, etc…)


Current Nutrition Knowledge


How ready are you to make the necessary dietary changes?
Not ready to changeThinking about changesPreparing to make changesActively making changesContinuing current changes

How motivated are you to make the necessary dietary changes?
Not motivatedSomewhat motivatedMotivatedVery motivated


Current Physical Activity Habits


Are you currently engaging in physically activity outside of daily work/tasks?
YesNo

How many days a week do you engage in physical activity?

How many minutes per day?

What type of physical activity do you engage in? (i.e. cardiovascular, strength/resistance, core)
WalkingRunningSwimmingGolfingDancingBike ridingTennisSports (basketball, softball, etc.)Weight lifting / Strength trainingAerobicsOther

If you do strength exercises, what type of strength exercises do you perform? (body weight, resistance bands, weights, machines)
Body weightResistance bandWeightMachineOther

On a scale of 1-10 how would you describe your accessiblity to an area to walk?
Not walkable23456789Very walkable

On a scale of 1-10 do you have a place you can be physically active?
No availability23456789Excellent availability


Nutrition Knowledge


How familiar are you with all of the information provided on the food label?
Not familiar at allSomewhat familiarFamiliarVery familiar

How familiar are you with the recommended amounts of servings from each food group as recommended by the USDA 2010 Dietary Guidelines?
Not familiar at allSomewhat familiarFamiliarVery familiar

How familiar are you with the myplate nutrition recommendations for balanced meals?
Not familiar at allSomewhat familiarFamiliarVery familiar

How would you rate your ability to prepare and cook meals/snacks for yourself?
InadequateBasicModerateComprehensive

How would you rate your ability to plan meals/snacks?
InadequateBasicModerateComprehensive