Get Kumc New Patient Nutrition Assessment Form 2011-2025

Completing the KUMC New Patient Nutrition Assessment Form online is an essential step in evaluating your nutritional health and establishing a personalized plan. This guide provides comprehensive instructions to help you navigate each section of the form efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Start with the personal information section. Fill in your first name, middle name, and last name. Then provide your address, including city, state, and zip code.
3. Indicate your preferred method of contact by checking the relevant box. Provide your home, work, and cell phone numbers, as well as your email address.
4. Complete the demographic details including your birth date, age, height, weight, sex, and blood type by marking the appropriate responses.
5. In the family section, indicate your marital status, whether you have children, and if you are pregnant, including the due date if applicable.
6. List anyone you live with, including their ages, for a comprehensive view of your household.
7. Provide information about your primary care provider and the date of your last physical exam. Mention any other doctors or practitioners you are seeing.
8. Move on to the goals and readiness assessment section. Describe why you would like to visit the dietitian and outline your nutritional and health goals.
9. Identify up to three changes you would like to make regarding your health and nutritional habits. Discuss any challenges you may face in reaching these goals.
10. Fill out the past medical and surgical history section by indicating any diseases or symptoms you or your relatives have experienced.
11. Move through the medical symptoms questionnaire by rating various symptoms based on your experience over the past 30 days, providing specific totals for each category.
12. Document your current medications, supplements, and antibiotics, along with their respective dosages and frequency.
13. Provide insight into your lifestyle, including physical activity, stress levels, sleeping patterns, and any substance use.
14. Discuss your weight history and any recent concerns regarding weight changes.
15. Detail your digestive and diet history, including any special diets, allergies, or difficulties you face related to food preparation and consumption.
16. Lastly, review your responses, make any necessary edits, and save your changes. You can then download, print, or share the completed form as needed.

Complete the KUMC New Patient Nutrition Assessment Form online today to take the first step towards improving your nutritional health.