Evaluation for Diet Interview

Patient/Client Brief Diet History

Patient/Client Initials:_______ Age:_______ Sex:_______

Eating Style:

Financial Status:

Living Conditions/Arrangements:

Cultural Influences on Eating Style:

Available Cooking Facilities:

Previous Diet Instruction/Past Experience with Dieting:

Oral/Vitamin/Mineral Supplement Usage:

Physical Activity:

Disabilities:

USUAL FOOD INTAKE Use back page as needed

Food Consumed Meal Time (Types and Amounts) (when food is consumed)

BREAKFAST LUNCH DINNER SNACKS

Assessment:

Care Plan (List Outcome Objectives)

Signature__________________________

WRITE AN ADIME STYLE NOTE AND A PES UTILIZING THE ABOVE INFORMATION.