Assessment Form – food-therapy

Name:

DOB:

Marital status Single Married Divorced Widow

Age::

Height:

cms/inches

Weight:

kgs/lbs

Area Code

Mobile

Email:

Address:

Occupation:

PERSONAL HEALTH HISTORY

Diet - Veg Non veg

Bowels

Regular Irregular

Sleep - Sound Disturbed

No.of Hours of sleep:

Daily water intake

How many meals you eat per day?

How many snacks you eat per day?

How many times in a week you eat outside

What kind of cuisine do you eat most of the time in a restaurant

Which cooking oil do you use? What is the total oil intake per month of a family?

Who cooks food at home?

Favourite food items

Food item or any food ingredient you dislike

HEALTH HABITS

Exercise

Sedentary(Noexercise)

Mild exercise (i.e., climb stairs, walk 3 blocks,golf)

Occasional vigorous exercise (i.e., work or recreation, less than 4x /week for 30min.)

Regular vigorous exercise (i.e., work or recreation 4x/week for 30minutes)

Alcohol

Do you drink alcohol?

Yes No

If yes, what kind?

How many drinks per week?

Caffeine

None

Coffee

Tea

Cola

Mention your Health Problems

List your prescribed drugs and over the counter drugs

Name the Drug

Strength

Frequency Taken

Any Operation done? Yes, then please mention

Food Allergies

FAMILY HEALTH HISTORY

FATHER:
Significant Health Problems

MOTHER:
Significant Health Problems:

GRAND FATHER:
Significant Health Problems:

GRAND MOTHER:
Significant Health Problems:

DIET RECALL (MENTION THE AMOUNT)

	Breakfast	Mid Morning	Lunch	Evening Snack	Dinner	Bed time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday