Assessment

Dietitian Assessment Form

The more you share, the more personal your plan becomes. Only your name is required — fill whatever you can.

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1. Patient & Consultation Details

Patient Name *

Date of Birth

Age

Gender

Contact Number

Email Address

Address/City

Occupation

Marital Status

Consultation Date

Consultant/Dietitian Name

Referred By

Preferred Language

Emergency Contact Name and Number

2. Anthropometric Assessment

Height

Current Weight

Usual Weight

Target Weight

Highest Adult Weight

Lowest Adult Weight

Recent Weight Change

Weight Change Duration

Waist Circumference

Hip Circumference

Mid-Upper Arm Circumference

Body Mass Index (BMI)

Body Fat Percentage

Visceral Fat Level

Muscle Mass

Blood Pressure

Pulse Rate

Weight

3. Primary Health Concerns

What is your main health concern?

When did the concern begin?

What symptoms are you currently experiencing?

How frequently do the symptoms occur?

Has the condition been medically diagnosed?

What factors make your symptoms better or worse?

Have you previously taken treatment for this condition?

Have you followed a diet plan before?

What results did you experience from previous plans?

What do you expect from this consultation?

What are your top three health goals?

4. Medical History

Do you have any diagnosed medical conditions?

Have you undergone any surgery?

Have you ever been hospitalized?

Do you have a history of frequent infections?

Do you experience chronic pain or inflammation?

Are you currently under a doctor's care?

Do you have difficulty chewing or swallowing?

Have you recently experienced fever, illness or injury?

Do you have any physical disability or mobility restriction?

Additional Medical Information

Medical Conditions Checklist

DiabetesPrediabetesInsulin ResistanceThyroid DisorderHypertensionHigh CholesterolFatty LiverKidney DiseaseHeart DiseaseAnaemiaArthritisPCOS/PCODEndometriosisFibroidsInfertilityAutoimmune ConditionEating Disorder

Other Medical Condition

5. Family Medical History

Does your immediate family have a history of:

Family History

DiabetesThyroid DisorderObesityHypertensionHeart DiseaseHigh CholesterolCancerPCOSInfertilityAutoimmune Disease

Other Family History

6. Medication & Supplement History

Which medicines are you currently taking?

What is the dosage and frequency of each medicine?

Since when have you been taking them?

Are you taking any vitamins or nutritional supplements?

Are you taking herbal or Ayurvedic products?

Have you recently stopped any medication?

Have you experienced side effects from any medicine?

Do you regularly take antacids, laxatives or painkillers?

Has your doctor prescribed any dietary restriction?

7. Food Allergy & Intolerance Assessment

Do you have any medically diagnosed food allergy?

Which foods cause an allergic reaction?

What type of reaction do you experience?

Are you intolerant to milk or dairy products?

Do wheat or gluten-containing foods cause discomfort?

Which foods commonly trigger digestive symptoms?

Are there foods you avoid for personal, religious or cultural reasons?

Have you ever followed an elimination diet?

Do you carry emergency medication for a severe allergy?

8. Current Dietary Pattern

What type of diet do you follow?

Who prepares your meals?

How many meals do you eat daily?

At what times do you usually eat?

Do you skip any meals?

Which meal do you skip most frequently?

Do you follow fixed or irregular meal timings?

How quickly do you finish a meal?

Do you eat while watching television or using your phone?

Do you usually eat alone or with family?

How frequently do you eat outside or order food?

Do you eat late at night?

Do you measure or control portion sizes?

How hungry do you feel before meals?

How full do you feel after meals?

Do you read nutrition labels?

Do you add extra salt or sugar to food?

9. 24-Hour Dietary Recall

Record food, quantity, time and preparation method.

Early Morning

Breakfast

Mid-Morning

Lunch

Post-Lunch

Evening Snack

Dinner

Bedtime

Foods or Drinks Consumed During the Night

10. Food-Frequency Assessment

How frequently do you consume:

Fruits

Green Leafy Vegetables

Other Vegetables

Whole Grains

Pulses and Legumes

Milk and Dairy Products

Eggs

Chicken

Fish

Red Meat

Nuts and Seeds

Fried Foods

Fast Food

Packaged Snacks

Sweets and Desserts

Bakery Products

Sugary Drinks

Tea

Coffee

Energy Drinks

Alcohol

11. Cooking & Food Preparation

Which cooking oil do you use?

How much cooking oil is used by the family each month?

How many people share that quantity?

Which cooking methods are commonly used?

Do you reuse cooking oil?

How frequently do you consume fried food?

Do you use packaged sauces or ready-made seasonings?

How much salt is used during cooking?

Do you consume processed or ready-to-eat meals?

Is food usually freshly prepared or reheated?

12. Appetite, Hunger & Cravings

How would you describe your appetite?

Do you experience intense hunger between meals?

At what time do you experience cravings?

Which foods do you crave most?

Do you crave sweet, salty or fried foods?

Do you eat in response to stress, sadness or boredom?

Do you experience loss of control while eating?

Do you feel guilty after eating?

Do you continue eating after feeling full?

Do you wake up at night to eat?

Do you experience dizziness or weakness when hungry?

13. Digestive Health

How frequently do you pass stool?

What is the usual consistency of your stool?

Do you experience constipation?

Do you experience loose motions?

Do you have gas or excessive burping?

Do you experience abdominal bloating?

Do you have acidity or heartburn?

Do you experience abdominal pain after eating?

Do you feel nauseous?

Do you notice undigested food in your stool?

Do you experience incomplete bowel evacuation?

Is there mucus or blood in the stool?

Have you recently used antibiotics?

Have you been diagnosed with IBS, IBD, gastritis or ulcers?

14. Hydration Assessment

How much water do you drink daily?

Do you feel thirsty frequently?

What is the usual colour of your urine?

How many times do you urinate daily?

Do you drink water immediately after waking?

Do you drink water with meals?

How many cups of tea or coffee do you consume?

Do you consume soft drinks, packaged juices or energy drinks?

Do you consume coconut water, buttermilk or herbal beverages?

15. Sleep Assessment

What time do you usually sleep?

What time do you usually wake up?

How many hours do you sleep?

How would you rate your sleep quality?

How long does it take you to fall asleep?

Do you wake up during the night?

Do you feel refreshed after waking?

Do you snore?

Do you use a phone or television before sleeping?

Do you sleep during the daytime?

Have you been diagnosed with sleep apnoea?

Do you use sleeping medication?

16. Physical Activity Assessment

What is the nature of your occupation?

How many hours do you sit daily?

What type of exercise do you perform?

How many days per week do you exercise?

What is the duration of each session?

What is the intensity of your exercise?

How many steps do you take daily?

Do you walk after meals?

Do you perform strength training?

Do you practise yoga or pranayama?

Do you have any exercise-related pain or restriction?

Which physical activity do you enjoy?

What prevents you from exercising regularly?

17. Stress & Emotional Well-Being

How would you rate your current stress from 1-10?

What are the main causes of stress?

How do you usually manage stress?

Does stress affect your appetite?

Do you experience anxiety or frequent worrying?

Do you experience persistent sadness or low mood?

Do you have difficulty concentrating?

Do you feel emotionally supported?

Are you currently receiving psychological counselling?

Have emotional concerns affected your ability to follow a diet plan?

18. Energy & Daily Symptoms

Do you experience

Persistent FatigueLow Morning EnergyAfternoon Energy CrashHeadachesDizzinessPoor ConcentrationBrain FogMuscle WeaknessJoint PainHair FallBrittle NailsDry SkinAcneSwellingFrequent CravingsMood ChangesFeeling Cold Frequently

At what time is your energy lowest?

Do any foods noticeably affect your energy?

19. Menstrual History

At what age did your periods begin?

Date of last menstrual period

What is your average cycle length?

Are your periods regular?

How many days does bleeding last?

How would you describe the menstrual flow?

Do you pass blood clots?

Do you experience period pain?

Do you experience spotting between cycles?

Do you experience PMS symptoms?

Have your periods stopped for three months or longer?

Have you been diagnosed with PCOS, endometriosis, cysts or fibroids?

Do you experience acne or unwanted facial hair?

Are you taking hormonal medication or birth-control pills?

20. Pregnancy & Fertility History

Are you currently pregnant?

Expected delivery date

Are you currently breastfeeding?

Are you trying to conceive?

For how long have you been trying?

How many previous pregnancies have you had?

How many live births have you had?

Have you experienced a miscarriage?

Have you undergone fertility treatment?

Are you currently taking fertility medication?

Have you been advised to gain or lose weight before conception?

Do you have any pregnancy-related dietary restrictions?

21. Hormonal & Menopause Assessment

Are you experiencing hot flashes?

Do you experience night sweats?

Have you noticed changes in mood or sleep?

Have you experienced sudden weight gain?

Do you experience vaginal dryness?

Are you in perimenopause or menopause?

Are you using hormone-replacement therapy?

Have you noticed reduced bone strength or frequent fractures?

22. Laboratory & Clinical Investigations

Enter value with date and remarks where available.

Haemoglobin

Total Leucocyte Count

Platelet Count

Ferritin

Serum Iron

TIBC

Transferrin Saturation

Vitamin B12

Folate

Vitamin D

Calcium

Magnesium

Fasting Blood Sugar

Postprandial Blood Sugar

HbA1c

Fasting Insulin

HOMA-IR

Total Cholesterol

HDL Cholesterol

LDL Cholesterol

Triglycerides

Uric Acid

TSH

Free T3

Free T4

Prolactin

FSH

Estradiol

Progesterone

AMH

Testosterone

DHEAS

SHBG

CRP/hs-CRP

ESR

SGOT/AST

SGPT/ALT

ALP

GGT

Bilirubin

Creatinine

Urea

23. Ultrasound & Imaging Findings

USG/TVS Date

Cycle Day

Uterus Findings

Endometrial Thickness

Right Ovary Findings

Left Ovary Findings

Right Antral Follicle Count

Left Antral Follicle Count

Presence of Cyst, Fibroid or Mass

Other Findings

Clinical Impression

24. Readiness & Goal Assessment

Why do you want to make dietary changes now?

How important is this goal to you on a scale of 1-10?

How confident are you about following the plan?

What difficulties may affect your progress?

Who can support you during this journey?

How much time can you give to meal preparation?

Which dietary changes are you willing to make?

Which changes would be difficult for you?

What would successful progress look like for you?

How would you prefer your progress to be monitored?

25. Dietitian's Clinical Assessment

For clinic use.

Nutritional Status

Identified Nutritional Deficiencies

Possible Root-Cause Factors

Priority Health Concerns

Estimated Energy Requirement

Estimated Protein Requirement

Daily Water Requirement

Dietary Restrictions

Initial Nutrition Goals

Recommended Medical Referral

Recommended Follow-up Tests

Proposed Plan Duration

Next Review Date

26. Follow-Up Assessment

For clinic use.

Current Weight (follow-up)

Waist/Inch Loss

Changes in Symptoms

Improvement Observed

Difficulties Faced

Diet Adherence

Exercise Adherence

Sleep Changes

Digestion Changes

Energy Changes

Laboratory Improvement

Required Plan Modifications

Next Follow-up Goal