Nutrition Assessment

Visit type:

Initial

Follow-up

S — Subjective

Dietary Pattern Snapshot

Recall Window

Recall Method

Seven Day Recall

Recall Start

YYYY-MM-DD

Recall End

YYYY-MM-DD

Recall Window Days

days

Subjective ratings

Hunger

Rate how urgently your body is signaling a need for fuel before meals. 0 is a physical emergency (shaky/weak); 5 is neutral; 10 is constantly ravenous.

012345678910

Satiety

Rate the physical sensation of fullness after meals. 0 is empty/starving; 6 is comfortably satisfied; 10 is painfully full or sick.

012345678910

Cravings

Rate the intensity of your desire for specific foods. 0 is no specific desire; 5 is present but ignorable; 10 is an overwhelming 'must-have-now' urge.

012345678910

Post-Meal Energy

Rate your energy level 30–60 minutes after eating. 0 is a 'food coma' or extreme fatigue; 5 is stable/steady; 10 is highly energized.

012345678910

Food Group Intake Frequencies

Food Groups List Add Food Group

No food groups recorded.

Nutrient Aggregates

kcal

Protein (g)

Carbs (g)

Fat (g)

Fiber (g)

Added sugar (g)

Sodium (mg)

Nutrition Report Document

No nutrition report attached

Notes

Dietary patterns, dietary restrictions, nutritional compliance...

Recall Window

Recall method:

24-hour

7-day

Food frequency

Other: ________

Recall start:

Recall end:

Recall window (days):

Subjective Ratings (0–10)

Hunger:

Satiety:

Cravings:

Post-meal energy:

Food Groups

Food Group	Frequency / servings	Notes

Nutrient Aggregates

Nutrient	Amount	Nutrient	Amount
Energy (kcal)		Fiber (g)
Protein (g)		Added sugar (g)
Carbs (g)		Sodium (mg)
Fat (g)

Nutrition report attached:

Notes:

Diet History & Intake Context

Meal timing / pattern:

Protein / fiber / fluid intake:

Appetite & cravings:

Food sensitivities / intolerances:

Access / food security:

Cultural / religious preferences:

Supplement use:

General - Nutrition Assessment for Doctor

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