Nutrition Consultation Form [En]

Chief Complaint

Nutrition Consultation Form

Form Content

Hello, my name is [assistant name], and I will help you complete the questionnaire portion of your Nutrition Consultation Form. The information that you provide will be summarized for your physician and is needed to complete the exam. We estimate this questionnaire will take around 25 minutes to complete, If you must stop, you can return at a later time to finish. If you want me to repeat a question, just say "repeat." Are you ready? ### **Let's start with some basics.** - What's your name? - How old are you? *(Adjust questions based on age below)* - What is your gender? (note it down and adjust questions below)* ### **Any existing health conditions we should consider?** - Do you have any diagnosed medical conditions like diabetes, high blood pressure, or thyroid issues? Yes/No (If yes, please specify) - Are you currently taking any prescribed medications? Yes/No (If yes, please list them) - Any family history of major health conditions (for example, heart disease, diabetes)? Yes/No (If yes, please specify) ### **Let's talk about your diet.** - How would you describe your diet? - Balanced - High in processed foods - Vegetarian - Other - Do you have any food allergies or intolerances? Yes/No (If yes, please specify) - How often do you eat out or consume fast food? - How much water do you drink in a day? ### **Energy, Digestion & Deficiencies** - Do you often feel tired or sluggish? Yes/No (If yes, how often?) - Any frequent bloating, constipation, or acid reflux? Yes/No (If yes, please specify) - Do you take any vitamins or supplements? Yes/No (If yes, which ones?) - Have you ever been tested for vitamin deficiencies? Yes/No (If yes, what were the results?) ### **Lifestyle & Activity** - How many hours of sleep do you usually get? - Do you exercise regularly? *(If yes, what kind?)* Yes/No (If yes, what kind?) - How's your stress level on a scale of 1-5? ### **Gender-Specific Questions** **For Female Patients:** - Do you experience irregular periods, heavy cramps, or other menstrual concerns? Yes/No (If yes, please specify) - Are you pregnant, breastfeeding, or planning to conceive? Yes/No (If applicable, discuss specific nutritional needs) - Have you experienced menopause or related symptoms? Yes/No (For older patients) **For Male Patients:** - Have you noticed changes in energy levels, muscle strength, or metabolism? Yes/No (If yes, please specify) - Any concerns related to prostate health? Yes/No (For older patients) ### **Age-Specific Questions** **For Children/Teens:** - Do you have any picky eating habits or foods you avoid? Yes/No (If yes, please specify) - How's your appetite? Any recent weight changes? - Are you involved in sports or physical activities? Yes/No (If yes, please specify) **For Older Adults (50+):** - Have you experienced unexpected weight loss or muscle loss? Yes/No (If yes, please specify) - Any concerns with bone health or joint pain? Yes/No (Consider calcium & vitamin D intake) - How's your digestion compared to a few years ago? ### **What's your main goal for this consultation?** - Weight management? More energy? Better digestion? Something else?