health assessment

Nutrition Assessment Forms & Questionnaires

Nutrition Assessment Forms & Questionnaires

Nutrition Assessment Forms & Questionnaires

& WELLNESS

Name

Best

Contact

Agreement of Participation and Confidentiality

Your signature below indicates your permission and willingness to participate in the below assessments, questionnaires and interviews and consider the potential program or recommendations, including interviews, counseling, medical nutrition therapy, personal training sessions and subsequent dietary/nutrition/exercise/health recommendations. All information and data discussed, written, typed, or communicated will be strictly confidential between the patient and the Odom Health & Wellness healthcare team.

You agree that the information you provide in the forms, assessments and interviews is accurate and current to the best of your ability. The OHW team commits to helping you reach your goals; encouraging and motivating you to overcome obstacles; equipping you to make healthy decisions and not giving up on you or your goals.

You also acknowledge that OHW is not solely responsible for your complete healthcare and needs to understand and be made aware of any changes or concerns in your health.

C/' z S 23 Signature:Date:

1

O DO tvl HEALTH & WELLNESS

Nutrition Assessment

Today's Date: Current Weight: Normal Weight:

Section 2: Health History

Name/Description	Dosage/Quantity		Frequenc	Start Date	Stop Date
Example: Metformin	500mg		2x/day	1/5/2015	Current

an	medical conditions	or diagnoses you have been treated for with prescriptions, surgery, or other medical care in the last 5

1, List years.

2. List any seasonal allergies and/or food allergies, sensitivities or intolerances,

3. Please list all of the following taken currently or within the last year: medications, hormone replacement therapies, antibiotics or other medically related medications or remedies. (Vitamins, minerals, nutraceuticals, etc will be asked for in a different section.)

4.

	Please indicate if you or a blood relative have been diagnosed with or experienced any of the following conditions or symptoms.	Self or Family Member?	Specifics (Date, Explain, etc)
	Allergies (please specify type of allergy)
	Anemia
	Anxiety or Panic Attacks
	Arthritis (osteoarthritis or rheumatoid)
	Asthma
	Autoimmune condition (specify type)
	Bronchitis
	Cancer (specify type)
	Chronic Fatigue Syndrome

	Crohn's Disease or Ulcerative Colitis
	Depression
	Diabetes (Specify: Type I UPrediabetes, Gestational Diabetes)
	Dry, itchy skin, rashes, dermatitis
	Eczema
	Emphysema
	Epilepsy, convulsions, or seizures
	Eye Disease (please specify)
	Fibromyalgia
	Food Allergies or Sensitivities
	Fungal Infection (athlete's food, ringworm, other)
	Gallbladder Disease/Gallstones (specify)
	Gout
	Heart attack/Angina	—/-z8ml	/lzo-h
	Heartburn
	Heart disease (specify)
	Hepatitis
	High blood fats (cholesterol, triglycerides)
	High blood pressure (hypertension)
	Hypoglycemia (low blood sugar)
	Intestinal Disease (specify)
	Inflammatory Bowel Disease (Crohn's or Ulcerative Colitis)
	Irritable bowel syndrome
	Kidney disease/failure or Kidney stones
	Lung disease (specify)
	Liver disease
	Mononucleosis
	Osteoporosis
	PMS
	Polycystic Ovarian Syndrome
	Pneumonia
	Prostate Problems
	Psychiatric Conditions
	Seizures or epilepsy
	Sinusitis
	Sleep apnea
	Stroke
	Thyroid disease (hypo- or hyperthyroid)
	Urinary Tract Infection
	Other (describe)
	Injuries
	Back injury
	Broken (specify)
	Head injury
	Neck injury
	Other (describe)

Nutrition Assessment Forms & Questionnaires ODOM HEALTH

Nutrition Assessment Forms & Questionnaires

Nutrition Assessment Forms & Questionnaires ODOM HEALTH &

	Diagnostic Studies
	Barium Enema
	Bone Scan
	CAT Scan: Abdomen, Brain, Spine (specify)
	Chest X-ray
	Colonoscopy or Sigmoidoscopy (specify)
	EKG
[3	Liver scan
C]	NMR/MRI
[3	Upper Gl Series
C]	Other (describe)
	Operations
C]	Dental Surgery
	Gall Bladder
	Hernia
	Hysterectomy
	Tonsillectomy

5 o you have complaints about any of the followi g?

Appetite Constipation Menstrual difficulties

Bleeding gums Diarrhea Seeing in dim light

Bruising Edemaudden weight change frChewing or swallowing Indigestiontress

6. Do you use tobacco in any way? Yes How much? Did you recently stop smoking? Yes no

MD

7, Are you currently seeing any healthcare providers that you would like to include in your nutrition care and plans?

Section 4: Nutrition History

hat chan like to nutrition concerns do ou ha e?

1 .	e in your hea e-JJ	h or nutrition h bits would you make? W}pt

2. Do you follow a special dietary plan prescribed by a medical provider or for religious reasons? Examples include: low cholesterol, kosher or vegetarian?

3. Have you ever chosen to follow a special diet, eating pattern, trai ing meal plan? Examples include: Paleo, Weight Watchers, Atkins, marathon training eating plan or off-season eating plan. Yes no

Name/Description of Diet or Plan	Dates Followed (List multiple dates if more than once)	Outcomes

4. Please list all vitamins, minerals, herbals, supplements, ergogenic aids, performance enhancers, protein powders, meal replacements or other nutraceuticals you are currently taking or have taken/used in the past year.

5. Do you tend to eat at regular or set times each day? Yes C] No What are they or explain?

6. Are there certain foods that you do not eat ever? Why?

7. What beverages do you typically drink within a week and how much?

8. How much water do you drink daily?

9. Do you drink energy drinks? a-fes No What and how often?

Home/House/Apartment		Provided Eating Area	[3 Food Carts
Desk	ar		Other:

10. Where do you eat on a regular basis? Check all that apply.

Room (Specify estaurants

Nutrition Reca// Please write out a list of your typical food and beverage intake,

Nutrition Assessment Forms & Questionnaires ODOM HEALTH &

Nutrition Assessment Forms & Questionnaires ODOM HEALTH &

Nutrition Assessment Forms & Questionnaires ODOM HEALTH &

Name/Description	Dosage/Quantity	Frequency	Start Date	Stop Date
Example: One A Day Men's Multi Vitamin	1200mg	Daily	1/5/2015	Current

Time Food/Meal Description

1 1. Eating Style: Based on how you eat on a regular basis, please check all that apply.

Fast eater D/Lgve to eat

Family members have different Ü/Émotional eater (stressed, bored, tastes sad, etc.)

Erratic eater Eat too much

Amount Eaten

Cl Eat because I have to

Q/fer dinner nibbler ate night-eater Dislike "healthy" food

Travel frequently Poor snack choices razer or snack through the day

Do not plan meals/menus	O Negative relationship with food	[3 Three square meals in the day
Cl Rely on convenience items	Struggle with eating issues	Cl Feed the family and then myself
Love to cook	Eat to look good	C] Eat healthy but don't like my body
[JHate to cook	Eat to be healthy
C] Confused about food/nutrition	Eat for athletic performance

Section 5: Weight History (Please do not complete this section if this is not relevant to your visit.)

1. Would you like to be weighed and/or measured today for a body composition assessment? Cl Yes O No

2. Height Current Weight Desired Body Weight

3. Highest Adult Weight When? Weight 1 year ago

4. Have you had any recent changes in your weight, percent body fat or lean muscle mass you're concerned about? C] Yes [3 No If yes, please explain:

6. What type of assistance are you hoping to receive today and in the upcoming months regarding your weight?

7,

Have

you

made

any

food

changes

recently

in

your

life

you

feel

good

O

Yes

are

they?

8. Please add any additional information you feel may be relevant to understanding your weight health.

Please explain:

5. Please indicate how often you experience the following s mptoms: (circle one for each)

Heartburn	Often	Sometimes	arel
Gas		Sometimes	Rarely
Bloating	fteh	Sometimes	Rarely

Stomach Pain Often Sometimes Nausea/Vomiting Often Sometimes

arely

Diarrhea Often Sometimes

Constipation Often Sometimes

Section 7: Activity and Exercise History

1 . Do you enjoy physical activity? No Explain:

2, Which of the following describes the amount of moderate or vigorous activity you have maintained in the past 2-6 months. This only includes purposeful movement you do in addition to your normal daily routine, most days:

Cl Les. than 30 minutes C] More than 120 minutes

(OBO-60 minutes More than 180 minutes

Cl More than 60 minutes Participate in elite or professional sports/training

Activity		Type/lntensity (low-moderate-high)	Days per Week	Duration (Minutes)
Stretching/Yoga
Cardio/Aerobics (Walk, jog, bike, swim, elliptical) List:
Strength-training (Weight lifting, Pilates, advanced yoga) List:
Recreational Sports (Basketball, soccer, slow pitch)
Elite Sports or Training (Marathon, triathlon, sports)
Leisure (Lawn games, gardening, etc)
Other (specify/describe)

3. Please indicate all types of activity and duration you regularly participate in:

4. Do you have any barriers to some or all types of activity?

5. Do you currently have anyone assisting you or training you in your exercise? Are you interested in a fitness assessment or customized training program? ( *This is a complimentary offer to assist you in your nutrition-related goals.)

Section 8: Performance and Elite Exercise (Please do not complete if not relevant to your lifestyle or visit.)

1, Explain the elite training or sports you participate in.

Type/Description	Details	Frequency/Duration per week	Months/Years of Participation	PR/Goals/Upcoming Events

2. Please write out your typical training and event schedule, (weekly, monthly or applicable time frame)

3. Do you eat or drink any pre-workout, pre-competition, post-workout or post-competition foods, meals, bars, supplements or beverages? Please list and/or explain

O DC) NVI & WELLNESS

4. Have you ever received or currently receive sports nutrition advice? What and are you still implementing?

5. What nutrition-related questions or concerns do you have regarding your performance or training?

Section 9: Socioeconomic History

1 . Circle the last year of school attended:
1 2 3 4 5 6 7 8 9 10 1 1 1 2	1 2 3 4	M.A.	Ph.D.
Grade School High School Other type of school	Cpl!ege

2. Are you employed? Occupation working inside the home or telecommuting C] Part Time working inside the home raising a family Full Time working outside the home Student

3. Present marital status (circle one):

Engage

Single Married Divorced Widowed Separated

1. Do you have a refrigerator? 3 Stove?

2. Who typically buys food, groceries and/or meals for your household?

3, How many meals per week do you eat that are home-cooked or prepared? Breakfast

4.

Please

write

the

names

and

ages

of

any

children,

if

any.

4. Who prepares most of the meals in your home?

5. Do you have any problems purchasing foods that you want to buy?

6. Do you use convenience or "fast foods" daily? es No Describe

Where?

7.

How

often

8. Drug use? DKever [3 In the past Currently C] Prefer not to discuss Type/frequency

9. How do you sp nd the majority of your days? Job, occupation, volunteering, etc. Please describe and list number of hours/week.

10. How much time do you spend in a car or public transportation most days?

1 1. Does anyone outside your immediate family live in your household? Whom?

12. How many hours of sleep do you get each night? Weekdays Weekends

Section 1 1 : Stress

1 , Please rate your overall stress level. No Stress 1 2 3 4 A lot of Stress

2. Indicate daily stressors nd rate the level of stress from 1 (e tremely low) to 10 (extremely high): Work Family Social Financial Health Other

4. What helps you to unwind?

5.

Are

you

able

to

do

the

above

Section 1 2: Goals and Desired Outcomes

6. If I could change three things about my health 90d nutritional habits, they would be•

7. 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/ready are you to...	1 2 3 4 5
Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (ex: work demands, sleep habits, physical activity)
Practice relaxation techniques
Engage in regular exercise/physical activity

Have periodic lab tests to assess your progress
Meet regularly with a dietitian

8. Please add any additional information you feel may be relevant to understanding your nutritional health.

9. Who could support and encourage you to make these changes?

Thank you for your wi//ingness to share this information, / look forward to working with you to make /ifesty/e changes to meet your food and fitness objectives.

Nutrition Assessment Forms & Questionnaires HEALTH

Nutrition Assessment Forms & Questionnaires ODOM HEALTH &

Nutrition Assessment Forms & Questionnaires ODOM HEALTH &

Food Frequency Questionnaire

Beverage Type	Daily Amount	Weekly Amount	Monthly Amount
Example: Coffee: Ø reg. O decaf, Cl Latte Oother	Two, 80z cups
Water: O tap Cl filtered bottled
Coffee: reg. decaf, C] Latte O other			Text
Tea: Obrewed Diced C]sweet Ocommercial brand
Juice: O natural Cl fruit drink C] smoothie Üjuicer
Cokes: regular diet
Milk: skim	D
Milk alternative:
Alcohol O wine beer Cl liquor
Sports Beverage:
Store Bought Drinks: Lemonade, V8, etc
Other:
How Often Do You Eat?	Never	2-3x/ month	1 x/week	2-3x/ week	1 x/day	2-3x/ day
Fast Food
Restaurant Food
Vending Machine Food
Cafeteria or Buffet Food
Frozen Meals
Home-Cooked Meals
Leftovers
Frozen Foods
Artificial Sweeteners, type:
Meal Replacements (bar, shake, etc) type:
Protein powder
Yogurt, type-
Cheese (natural, processed)
Cottage cheese
Milk desserts (pudding, custard, ice cream)
Beef (hamburger, steak, etc)
Pork (chop, loin, ham, bacon, etc)
Poultry (chicken, turkey, etc)
Fish (fresh, frozen, canned), type:
Deli Meat, Type:
Eggs
Dried beans, legumes
Peanut butter or almond butter
Nuts, seeds
Soyfoods (tofu, tempeh, TSP, flour)
Bread

How Often Do You Eat?	Never	2-3x/ month	1 x/week	2-3x/ week	Ix/day	2-3x/ day
Cereals
Pasta, noodles
Rice, quinoa, bulgur, oatmeal, etc
Cornbread, muffin, bagel, biscuit, pancake, pizza
Crackers
Popcorn
Cookies, cake, pie
Donuts, pop tarts
Chips, Cheetos, pretzels
Other packaged/processed foods
Orange/red/yellow vegetables (carrots)
Green vegetables (broccoli)
Leafy vegetables (Spinach, kale, collard greens)
Starchy vegetables (potato, rutabaga, squash)
Other vegetables
Orange/red/yellow fruits (orange)
Berries (strawberries)
Stone fruits (peach)
Other fruits
Butter, margarine
Cooking oil
Sour cream, mayonnaise, salad dressing
Candy

HEALTH

Inflammation and Nutrition Related Symptoms Questionnaire

Rate each of the following symptoms based upon your typical health profile for the past 30 days. If you have been having recent or somewhat severe health symptoms, please indicate that you will fill out the questionnaire for the past 48 hours,

Nutrition Assessment Forms & Questionnaires ODOM HEALTH &

Nutrition Assessment Forms & Questionnaires ODOM

Nutrition Assessment Forms & Questionnaires ODOM &

1

1

1

Point Scale:

0 = Never or almost never have the symptom

1 = Occasionally have it; effect is not severe

2 = Occasionally have it; effect is severe

3 = Frequently have it; effect is not severe

4 = Frequently have it; effect is severe

HEAD

I Headaches*

Dizziness

I—lnsomnia

Faintness* *

%TOTAL

Itchy ears

Ringing in ears/loss of hearing

Earaches/ear infections

Drainage from ear

CLTOTAL

EYES

I Bags or dark circles under eyes* Watery or itchy eyes

Swollen, reddened, or sticky eyelids

Blurred or tunnel vision (excluding near- or farsightedness) * —LTOTAL

Stuffy nose

Sinus congestion, sinus infection

Constant sneezing

Hay fever/allergies

Excess mucus formation*

TOTAL

MOUTH/THROAT

Chronic coughing

_l_Sore throat, hoarseness, loss of voice Gagging, frequent need to clear throat Swollen tongue, gums or lips* *

Swollen lymph nodes

QCanker sores, mouth ulcers* *

—LTOTAL

HEART

—LChest pain

Irregular or skipped heartbeat* *

Rapid or pounding heartbeat* TOTAL

Asthma, bronchitis

Chest,congestion

Shortness of breath

Difficulty breathing* *

TOTAL

Acne

Brown "age/liver spots"*

Hives, rashes, cysts, boils*

Dry skin

Eczema or psoriasis*

Itchy skin/dermatitis*

Flushing, hot flashes

Discoloration*

Skin tags*

Body odor

Excessive sweating

TOTAL

[NAILS air loss*

Brittle hair

Thinning Hair*

Brittle nails*

White crescents on nails*

Cracking nails*

Ridges or bumps on nails* * Thin nails* *

JOINTS/MUSCLES

Pain or aches in joints or lower back

Tingling or numbness* *

Stiffness or limitation of movement*

Arthritis*

Pain or aches in muscles

Weakness* * TOTAL

M NTAL/EMOTIONAL

Poor memory*

Difficulty concentrating* *

-LMood swings*

Depression* *

Anxiety, fear or nervousness

—I—Anger, irritability, or aggressiveness

Insomnia* *

TOTAL

E ERGY LEVEL

Fatigue/low energy* *

Sleepiness* * Restlessness* —LHyperactivity* a-Feeling of weakness*

TOTAL

WEIGHT

Underweight*

Overweight*

Difficulty losing weight*

Water retention*

Crave certain foods* *

TOTAL

D GESTIVE TRACT

Nausea, vomiting*

Diarrhea*

O DC) IVI HEALTH & WELLNESS

Bloated feeling*

Belching, passing gas*

Heartburn*

Intestinal/stomach pain* TOTAL

PMS*

Frequent colds, flus*

Chemical or environmental sensitivities

Food allergies/sensitivities* Frequent or urgent urination

Genital itch or discharge

TOTAL

GRAND TOTAL (A

1 5 or lower: low level of inflammation and nutrition influenced symptoms

1 6 to 49: moderate level of inflammation and nutrition influenced symptoms 50 or higher: high level of inflammation and nutrition influenced symptoms

*Indicates symptoms related to nutrition or nutrition-related conditions

** Indicates symptoms related to nutritional deficiency

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