Get Nutritional Screening Sheet

Completing the Nutritional Screening Sheet online can assist you in assessing your dietary needs and establishing a plan for improved nutrition. This guide provides step-by-step instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to complete your Nutritional Screening Sheet online.

1. Press the ‘Get Form’ button to access the Nutritional Screening Sheet and open it for editing.
2. Begin by entering your name, date of birth (DOB), and the current date at the top of the form. Ensure that all personal information is accurately filled in.
3. Provide the name of the referring healthcare provider, if applicable. This helps establish communication between your providers.
4. In the Medical/Social History section, indicate the reason for the nutritional consultation, your current diagnosis, any current medications, and any known medication allergies.
5. Fill in your diagnosed medical conditions or diseases, and provide details about your family's history of disease.
6. Record any recent laboratory test results for blood glucose, Hb A1c, total cholesterol, HDL, LDL, triglycerides, and blood pressure.
7. Next, enter your height, current body weight, age, and usual body weight, including your highest and lowest weight records along with the ages those occurred.
8. Indicate your smoking status and detail your alcohol consumption, including the amount and duration of use.
9. Respond to questions regarding your physical activity levels and types of activities you engage in regularly.
10. Move to the Diet History section to document any vitamin and mineral supplements, food allergies, dislikes, and your usual eating patterns.
11. Specify how often you eat out, consume fast food, and describe your typical eating environment.
12. State your primary goal for nutritional counseling, as this will guide your nutritional plan.
13. Complete the Diet Recall section by noting the number of servings per day and week for various food groups.
14. Address the Behaviors Past or Present section by indicating frequency for behaviors such as counting calories, dieting, or any restrictive eating patterns.
15. Once all sections are completed, review the form for accuracy. Save your changes, and choose to download, print, or share the completed Nutritional Screening Sheet as needed.

Start completing your Nutritional Screening Sheet online today for a thorough assessment of your dietary needs.