Minneapolis Department of Health and Family Support

School-Based Clinic Program

NUTRITION ASSESSMENT

Name / Birthdate / Grade / Age / Today’s Date
1. List the sport(s) you will participate in: ______
______Number of hours of practice weekly? ______
Other regular exercise? ______
What changes have you made or will you make in your food because of your sport(s)? ______
______
If some changes in the foods you are eating would improve your health, would you make those changes?
Definitely Probably Probably Not Definitely Not Don’t Know
Does your family usually eat meals together? Yes No
Who lives with you? Mom Dad Stepparent Other Relatives Siblings Other: ______
Who shops for food at home? ______Who prepares the food?______

2. How often do you feel out-of-control when eating? Often Once in a while Never
Have you ever vomited after eating? Yes No
How do you feel about your weight? O.K. I would like to weigh more I would like to weigh less
Have you ever tried to gain or lose weight before? No Yes, If yes, please describe: ______
______
Have you lost or gained a significant amount of weight in the past year? Yes No
Lost Gained How much did you lose or gain? ______
Do you often feel dizzy, faint or black-out during the day? Yes No
Check the times you usually eat: Morning Lunch After School Evening Before Bed
How many of the 5 school days do you eat breakfast per week? ______
How many of the 5 school days do you eat lunch per week? ______
How often do you eat in a restaurant per week? ______Where: ______

Are there any foods you do not or cannot eat? (ex., allergic, don’t like, religious reasons) Yes No
If yes, which foods don’t you eat? ______
What dietary supplements have you taken? Vitamins Powder/Liquid Protein Diet Pills
Herbal Supplements Other: ______
Do you use medications? (pain relievers, laxatives, etc.) Yes No
3. Are you now following any kind of special diet? Yes No
If yes, please describe: ______
Do you consider yourself a vegetarian? Yes No
If yes, what foods do you avoid? ______
What foods do you replace them with? ______
How often do you eat any of the following foods: carrots, spinach (greens), squash, pumpkin, cantaloupe, mango, sweet potato?
Everyday 3 to 4 times a week 1 to 2 times a week Less than once a week

(STOP)

037_Nutrition Assessment.doc Rev Jan 00

OK + -
HEIGHT: % TILE / WEIGHT: % TILE / EST. KCAL NEED: / EST. KCAL INTAKE: / Hgb:

24 HOUR RECALL

TIME /

FOOD AND AMOUNTS

/ S.
A.
FOOD GROUPS
/ AMOUNT / OK + -
DAIRY: 4-8 oz sv/day
PROTEIN: 4 oz/day
TOTAL VEG: 3 sv/day
TOTAL FT: 2 sv/day
VIT C: 1/day
VIT A: 3/week
BREAD/CEREALS: 6-11 sv/day
SWEETS / POP: 2/day
WATER
P.

037_Nutrition Assessment.doc Rev Jan 00