Nutrition Assessment Form

A nutrition assessment is an elaborate evaluation of patient-related data about dietary intake, lifestyle, and medical history. It is essential in improving food choices, health habits, and standard of living. Poor diet and lack of physical activity can result in physical weakness and deranged immunity.


Nutrition is the process of obtaining food that is necessary for the growth and health of an individual.

There are a few basic elements of nutrition. These are macronutrients (carbohydrates, fats, proteins, and water) and micronutrients (minerals and vitamins).

Malnutrition refers not only to food and energy deficiency (undernourishment) but also to the excess of nutrients (over nourishment). These should be taken into consideration as their effects may lead to an unbalanced life. This not only proves harmful physically but also deeply affects the social, personal, and mental health of a person. Its importance is especially vital in children as it shaped their whole lives.

Essentials of Patient Nutrition Assessment

There are a few essentials that have to be mentioned in the form of patient nutrition assessment, which comprises of ABCDs i.e. Anthropometric measurements (mentioned ahead), Biochemical (laboratory tests), Clinical (History and physical examination), and Dietary data (to determine if the patient is malnourished or well-nourished).

Patient Nutrition Assessment Form

The patient nutrition assessment form consists of the following parameters:

  • Patient’s name, father’s name, age, sex, blood group, mailing address, phone number, email id, marital status, employment, religion, race, children if any with ages, the status of pregnancy if any, and information about primary care provider.
  • Anthropometric measurements: height, measured weight, ideal weight, waist circumference, basal mass index (BMI), head circumference, mid-upper arm circumference (MUAC).  
  • History of previous or current illnesses if any. Duration of illness.
  • Information about sports or health goals.
  • Treatment, over-the-counter drugs, or supplementation history. Smoking or alcohol abuse with quantification. Allergies and food dislike if any.
  • The previous record of physical checkup. All laboratory investigations and radiological tests record.
  • Family medical history and any hereditary diseases.
  • Activity level: Sedentary (no exercise, gardening, or household work), Moderately active (exercise 3 to 5 times a week, 20 to 30 minutes each time), Active (exercise 3 to 5 times a week, 60 minutes each time), Very active (exercise 3 to 5 times a week, 90 minutes each time), Extremely active (exercise 5 or more times a week, more than 90 minutes each time)
  • List of all exercises done by the patient
  • Hours spent in different activities like watching TV, using a computer, hobbies, and recreational activities, frequency of vacations or trips, reading or studying.
  • Dietary habits include food/ meals (breakfast, lunch, dinner, and snacks) and beverages (water, tea, coffee, and juices). Eating pattern; eating disorders if any.
  • Quantifying stress (minimal, considerable, average, unbearable).
  • Cause of stress (health-related, job-related, financial, marriage, family related, interpersonal or spiritual).
  • Sleep patterns.
  • Undertaking by the patient.
  • Privacy and confidentiality agreement.
  • Name and signature of consenter.
Nutrition assessment form

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