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LSDP Initial Nutrition Assessment

This document contains an initial nutrition assessment for a diabetes patient. It collects information about the patient's medical history, current weight, physical activity level, meal and snack schedule, who does the grocery shopping and cooking, how food is usually prepared, frequency of eating out, types of restaurants frequented, food allergies or avoidances, alcohol consumption, willingness to make lifestyle changes, and a list of typical foods eaten at each meal and snack. The assessment is used to determine calories, carbohydrates, protein, fat and vegetable intake and to develop a nutrition care plan.

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Ma Alma Ocampo
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348 views1 page

LSDP Initial Nutrition Assessment

This document contains an initial nutrition assessment for a diabetes patient. It collects information about the patient's medical history, current weight, physical activity level, meal and snack schedule, who does the grocery shopping and cooking, how food is usually prepared, frequency of eating out, types of restaurants frequented, food allergies or avoidances, alcohol consumption, willingness to make lifestyle changes, and a list of typical foods eaten at each meal and snack. The assessment is used to determine calories, carbohydrates, protein, fat and vegetable intake and to develop a nutrition care plan.

Uploaded by

Ma Alma Ocampo
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Living Smart D i a b e t e s

INITIAL NUTRITION ASSESSMENT


Age __________ Sex: ___M ___F Height ________ Current Weight _______ lbs

Desired Weight ________ lbs Physical activity level: ____light ____moderate/heavy BMI __
History: High Blood pressure Kidney disease high Triglycerides High cholesterol

1. Has your weight change in the past three months? p Yes p No Weight lost / gain____ lbs
2. Which meals and snacks do you usually eat each day?
___Breakfast ___Lunch ___Supper ___Mid-morning snack
___mid-after snack ___evening/bed time snack ___during the night
3. Do you regularly skip meals? pYes pNo

4. Who does the grocery shopping? ______________Who does the cooking? ____________

5. How is your food usually prepared? pFried pBaked pBroiled pGrilled


6. How often is your meal away from home?
____ Daily ____ 1 to 3 times per week or less ____ more than 3 times per week

7. What type of restaurant do you eat or carry out?


pFast food pBuffet psit-down restaurant pother__________________
8. Do you avoid eating any foods? pYes pNo Food Allergies: _______________________
If yes, which ones?

9. Do you drink alcohol? pYes pNo


If yes, what type (s)? pLiquor/spirits pwine pwine coolers pbeer
How many serving do you usually take? p1 or more daily p2 to 5 weekly prarely

10. If you and your dietitian discover changes you could make in your lifestyle to improve your health, would
you be open to the changes? pYes pNo
If yes, who will support and encourage you? _____________________________________________
11. Any other special diet needs?

Please tell us the foods you usually eat: You may write this on a separate piece of paper.
BREAKFAST/Time: EDUCATOR TO COMPLETE THIS SIDE
BEE: ______ Calories/day: _____ Carbs/day: ______

%carbs ______ % protein_____ gms fat______


Food Eaten/Amount/How Prepared BREAKFAST
Grams of Carbs: Vegetables:

Comments: Meat: Fat:


LUNCH/Time:
Food Eaten/Amount/How Prepared LUNCH
Grams of Carbs: Vegetables:

Comments: Meat: Fat:


DINNER/Time:
Food Eaten/Amount/How Prepared DINNER
Grams of Carbs: Vegetables:

Comments: Meat: Fat:


SNACK/Time(s): SNACK Grams of carbs : 15
Food Eaten/Amount/How Prepared
Dietitian/Educator:______________________
Comments: Review Date_______________

Patient Name:_______________________________ Signature____________________ Date_______

LSDP Nutrition Assessment PT form (11/08)

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