Nutritional Assessment Form- Orbera Patients Katie Leahy, MS RDN LD

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Allison Horn
5 years ago
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1 Nutritional Assessment Form- Orbera Patients Katie Leahy, MS RDN LD First Name Last Name Please indicate your preferred method of contact: home cell text other: Sex: Male Female Birth date: / / Age: Height Current Weight Desired body weight Occupation Martial status Do you have children? Yes No Age of children Primary Care Physician: Personal History (check all at that apply): Arthritis Stroke High Cholesterol High Blood Pressure Diabetes Type 1 diabetes Type 2 diabetes Cancer What type? Surgeries What type? Thyroid Problems Hyperthyroid Hypothyroid Food Allergies To what? Depression Smoke Cigarettes Indicate daily stressors and rate the level of stress from 1 (low) to 10 (high): Work Family Social Finanical Health Other How many hours of sleep do you need to feel rested? How many hours do you get? To what extent will you commit to achieving better health? Little Moderate Major Extreme Is there anything additional about your health history that you feel is important to mention?

2 DIET HISTORY Are you currently taking any food or nutritional/herbal supplements? Yes No If yes, please indicate which ones: What meals do you eat regularly: Breakfast Lunch Dinner Snacks Who prepares the majority of your meals? Who shops for food? Food Dislikes Diet restrictions or limitations? (Health, cultural, religious, or other): Food Allergies or intolerances? Do you crave certain foods? Sweets Bread/Pasta Fried foods Alcoholic drinks Sodas Meat Other: Eating Style: Based on how you eat on a regular basis, please check all that apply Fast eater Erratic eater Emotional eater (stressed, bored, sad..) Late night eater Time constraints Dislike healthy food Travel frequently Do not plan meals/meus Rely on convenience items Family member(s) have different tastes Love to eat Eat too much Eat because I have to Negative relationship with food Confused about food/nutrition Fast food Graze/snack all day Poor snack choices The biggest challenge(s) to reaching my nutrition goals is/are: Do you want to change your eating habits? Yes No What are your expectations for the registered dietitian?

3 Beverage intake: Please indicate the beverages you drink, how often, and how much. Beverage Type Daily Amount Weekly Amount Example: Coffee: x Reg Decaf Latte 2-8oz cups Water: Coffee: Reg Decaf Latte Tea: Juice: Natural Fruit drinks Soda: regular diet Milk: Whole 2% 1% Skim Milk alternative type: Alcohol: Wine Beer Liquor Other:

4 Food Intake: Please indicate the frequency that you eat the following: How often do you eat: Fast Food Restaurant Food Vending Machine Food Cafeteria or Buffet Food Frozen Meals Home-Cooked Meals Leftovers Beef (Hamburger, steak, etc.) Pork (Chop, bacon, ham, etc.) Lamb Poultry (Chicken, turkey) Deli Meat, type: Fish, type: Soyfoods, type: Beans, type: Crackers, type: Cookies, cakes, muffins Whole grains, type: Fresh/raw/frozen/canned vegetables Fresh/frozen/canned fruit Margarine Dairy (milk, yogurt, cheese, butter) French Fries Fried Meat (chicken, fish) Artificial sweeteners, type: Meal Replacement, type: Other: Never month Once/ week week Once/ day day

5 Physical Activity Activity Type/Intensity (low-moderatehigh) # Days per week Duration (minutes) Stretching/Yoga Cardio (Walking, jogging, biking, etc.) Strength-Training (lifting weights) Sports or leisure Other (describe) Does anything limit you from being physically active? On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following: To improve your health, how willing are you to... Significantly modify your diet Keep a record of everything you eat daily Modify your lifestyle (ex. Sleep habits, physical activity) Engage in regular exercise/physical activity Follow up with the dietitian on a monthly basis via phone

Nutrition Assessment

Nutrition Assessment Today s Date: Basic Information Name: Age: Gender: Date of Birth: Phone Number: Email Address: I prefer to be contacted via (please circle): phone email Reason for your visit: Occupation: Do you have children?