Internal Medicine-Nutrition Assessment

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Submission Date
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Personal Information
First Name*
Last Name*
Email*
Phone*
Gender*
- Male
- Female
Date of Birth*
Month
Day
Year
Ethnicity*
Height*
Weight Information
Current Weight*
When did you last weigh yourself (or were mostly recently weighed)?*
MM slash DD slash YYYY
How often do you weigh yourself?*
When do you weigh yourself?*
What weight do you maintain with little effort?*
What was your average weight for the past year?*
At what weight do you feel most comfortable?*
What must you do to stay at that comfortable weight?*
If you've gained weight over the last 1-2 years, what would you identify as the primary cause?
What has been your highest adult weight?*

Please indicate weight and when.
What has been your lowest adult weight?*

Please indicate weight and when.
Have you ever been pregnant?*
- Yes
- No
What was your pre-pregnancy weight?
Please describe each pregnancy separately
How much weight did you gain?
Please describe each pregnancy separately
Were you able to lose all the weight gained with each pregnancy?
- Yes
- No
- Sometimes
Dieting & Weight Loss History
Have you ever tried to lose weight before?*
- Yes
- No
What type(s) of weight loss program(s) have you tried? (e.g. Weight Watchers, Low Carb, etc.)
Please describe each program, when you tried it, how much you lost, and how long it lasted.
What did you like about this (these) program(s)?
Have you ever been advised by your physician to follow a special diet? (e.g. Low sodium, low cholesterol, no sugar, etc.)*
- Yes
- No
If yes, when and what kind?
What changes did you make at that time?
Have you ever worked with a dietician or nutritionist before?
- Yes
- No
If yes, what was your experience?
Any additional comments you would like to add regarding your dieting and weight loss history?
Personal Medical History
Medical Diagnosis or Procedure(s)*
Please list any diagnosis or procedure(s) you have had that affected your appetite, caused weight gain/loss, or required management with medical nutrition therapy (e.g., Diabetes, Hypertension, etc.)
Medications*
Please describe all medications taken regularly, specifying the dose, frequency, and how long you've taken it
Recent Laboratory Tests
Cholesterol - Test Date
MM slash DD slash YYYY
Cholesterol - Test Result*
LDL/HDL - Test Date
MM slash DD slash YYYY
LDL/HDL - Test Result*
AST/ALT - Test Date
MM slash DD slash YYYY
AST/ALT - Test Result*
Triglycerides - Test Date
MM slash DD slash YYYY
Glucose - Test Date
MM slash DD slash YYYY
Glucose - Test Result*
Family History
Has anyone in your immediate family (blood relative) ever had any of the following diseases?*
- Diabetes
- Cancer
- Heart attack
- High blood pressure
- Kidney disease
- Stroke
- Other
Please describe who, and what condition they had
Does anyone in your family have issues with their weight?*
- Yes
- No
If yes, please explain
Personal Health History
Do you take vitamin, mineral, or food supplements?*
- Yes
- No
What supplements do you take?
Please list supplement, dosage, frequency, how long you have taken, and why
Who recommended the supplements?
Any additional comments regrading supplementation?
Do you have food allergies?*
- Yes
- No
If yes, please describe.
How and when were your food allergies diagnosed?
Do you have any food intolerances?*
- Yes
- No
If yes, please describe
Do you smoke?*
- Yes
- No
If yes, how much and for how long?
On average, how many hours do you sleep each night?*
Please rate your stress level*
Extremely low Low Somewhat low Somewhat high High Extremely high
What would you identify as your primary source of stress?*
What do you do to manage stress?*
Eating Patterns
How many days per week do you eat breakfast?*
Please enter a number from 0 to 7.
How many days per week do you eat lunch?*
Please enter a number from 0 to 7.
How many days per week do you eat dinner?*
Please enter a number from 0 to 7.
What are your favorite foods?*
What foods do you avoid, and why?*
How many meals and snacks do you eat per week that are NOT home cooked?*

Please include breakfast, lunch, dinner, snacks, and any meal you purchase
What type of restaurant(s) do you normally choose?*
- Mexican
- Italian
- Fast food
- Fast casual dining
- Fine dining
How often do you snack during the day?*
When do you typically snack?
- Select All
- Morning
- Midday
- Afternoon
- Evening
- Bedtime
- Other
What foods do you snack on most frequently?
How does your meal and snack pattern vary on the weekend, vs. during the week?*
Do you drink alcohol?*
- Yes
- No
If yes, what do you drink?
- Select All
- Beer
- Wine
- Mixed drinks
Number of alcoholic drinks per day?
Do you travel and/or entertain for your business?*
- Yes
- No
If yes, how often?
Awareness of Food and Eating Patterns
Do you eat standing up?*
Never Sometimes Often Always
Do you eat in the car?*
Never Sometimes Often Always
Do you eat at the kitchen/dining room table?*
Never Sometimes Often Always
Do you feel that you eat fast?*
Never Sometimes Often Always
Do you feel comfortable eating in front of others?*
Never Sometimes Often Always
Do you eat with others or alone most often?*
- Most often alone
- Most often with others
Kitchen Skills Assessment
Do you like to cook?*
- Yes
- No
- Sometimes
Do you cook?*
- Yes
- No
- Sometimes
If you don't cook, please explain how you nourish yourself.
If you cook from recipes, what sources do you typically use?
- Select All
- Magazines
- Cookbooks
- Family recipes
- Websites
Who typically prepares the food at home?*
Who typically does the grocery shopping?*
Do you read nutrition facts or ingredient labels?*
- Yes
- No
- Sometimes
If yes, what do you look for?
Eating and Emotions
Do you, or have you ever, used food for comfort or to address other emotions?*
- Yes
- No
If yes, please elaborate
What level of support do you need when making lifestyle changes?*
Extremely low Low Somewhat low Somewhat high High Extremely high
Do you have a strong support system?*
- Yes
- No
Exercise and Activity
Do you like to exercise?*
- Yes
- No
What, if any, physical activity do you dislike?
Do you currently follow a consistent exercise routine?*
- Yes
- No
If yes, how many days per week?
How long are your exercise sessions?
If no, when did you last follow a consistent exercise routine?
Please check all activities in which you currently engage*
- Cardio machines
- GX classes
- Strength training
- Yoga
- Walking
- Running
- Swimming
How often do you do some form of cardiovascular exercise?
- 3+ days per week
- 1-2 days per week
- Not at all
How often do you do some form of strength training?
- 3+ days per week
- 1-2 days per week
- Not at all
How often do you do some form of flexibility training?
- 3+ days per week
- 1-2 days per week
- Not at all
Do you neglect your exercise routine when you feel overwhelmed or life gets busy?*
- Yes
- No
- Sometimes
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Internal Medicine-Nutrition Assessment

Personal Information

Weight Information

Dieting & Weight Loss History

Personal Medical History

Recent Laboratory Tests

Family History

Personal Health History

Eating Patterns

Awareness of Food and Eating Patterns

Kitchen Skills Assessment

Eating and Emotions

Exercise and Activity

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