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Nutritional Assessment Form: General Information

The document contains a nutritional assessment form collecting information like name, age, height, weight, BMI, activity level, diet history, meal timing, water intake, sleep patterns, exercise habits, and a physical examination. It collects financial information and makes dietary recommendations.

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Maria malik
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530 views

Nutritional Assessment Form: General Information

The document contains a nutritional assessment form collecting information like name, age, height, weight, BMI, activity level, diet history, meal timing, water intake, sleep patterns, exercise habits, and a physical examination. It collects financial information and makes dietary recommendations.

Uploaded by

Maria malik
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NUTRITIONAL ASSESSMENT FORM

GENERAL INFORMATION

Date: Contact No.:

Name: Age:

Height: Weight:

BMI: Activity level:

BMR: Waist Circumference

Hip Circumference Waist to Hip Ratio:

Water Requirements: IBW:

Family Income and Expenditures

Total Family Income Total Expenditures

Total Family Members No. of Member Earning

No. Children No. of Old Age

Monthly Utility Bill Medical Expenditures

Diet History: Daily consumption of foods from each group:

Milk Products Bread and Cereals

Fruits Vegetables

Meat Fat

How often do you take Junk food________________times/week

Meal Timing Do you skip meals? If yes, which one?

Breakfast time: Breakfast

Lunch time: Lunch

Dinner time: Dinner

WATER INTAKE

Glasses/day:

SLEEP-WAKE CYCLE

Sleep time: Wake up time:


Total sleeping hours

EXERCISE AND WALK

Duration: Days/week:

Types of Exercise:

PHYSICAL EXAMINATION

Skin Healthy Dry Scaly Patchy

Mouth Normal Sores Altered Taste Sensation

Tongue Deep red Rough Raw Swollen Smooth

Nails Pink nail beds Smooth Firm Spoon Shaped

Eyes Dry membranes Redness red rimmed

Teeth Cavities Erupting abnormally Missing

Hair Dull Dry Thin Wire Like Sparse

DIETARY RECOMMENDATIONS

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