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Patients & Visitors
Visiting Hours
Make an Appointment
Patient Portal
Insurance & Billing
Medical Records
On-Site Amenities & Dining Options
Health Information Center
Gift Shop
University Pharmacy
Locations
Parking & Directions
Patient Experience
Medical Care
Medical Services
Find A Doctor
UT Urgent Care
Regional Health Centers
Specialty Practices
Directory of Services
Department Directory
Procedures & Treatments
Centers of Excellence
Brain & Spine Institute
Cancer Institute
Emergency & Trauma Center
Heart Lung Vascular Institute
Orthopaedic Institute
Primary Care Collaborative
Center for Women & Infants
Academics & Research
Academic Medical Center
Graduate School of Medicine
Pharmacy Residency Programs
School of Computerized Tomography
School of Medical Laboratory Science
School of Radiography
School of Vascular Interventional Radiography
Research
Clinical Trials
Health Care Professionals
Referring Physicians
Nursing Excellence
Careers
Education & Training
Team Member Resources
About
Our Story
Excellence & Achievements
UT Medical Center’s Mission, Vision and Values
Events Calendar
Connect
Newsroom
Diversity, Equity and Inclusion
Give Back
COVID-19 Donations and Support
Give Now
Ways to Give
Volunteer
Internal Medicine-Nutrition Assessment
Forms Directory
Internal Medicine-Nutrition Assessment
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Personal Information
First Name
*
Last Name
*
Email
*
Phone
*
Gender
*
Male
Female
Date of Birth
*
Month
Day
Year
Ethnicity
*
African American
Asian
Caucasian
Hispanic/Latino
Other
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?
*
Rarely
Occasionally
Daily
Weekly
Monthly
When do you weigh yourself?
*
Morning
Midday
Afternoon
Evening
Bedtime
Varies
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?
*
None
Once
Twice
Three times
Continually
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
Submission
Is there anything else that you think I should know about you?
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