UCLA Nutrition Education

Center for Human Nutrition Medical Nutrition Syllabus Guide to Healthy Diet and Lifestyle Exercise Guidelines Managing Obesity Exercise Prescription Medicine and Surgery Nutrition Assessment Checklist Pediatric Nutrition Assessment Checklist Adolescent Nutrition Assessment Checklist			ADOLESCENT NUTRITION ASSESSMENT CHECKLIST (This checklist is to prompt you during patient interviews You are required to fully complete this and turn it in with your nutrition write-up and growth charts. Include information that is relevant on the write-up.) Present Illness: Medical History: Does the teenager take any vitamins/minerals or food supplements? Yes/ No If yes, which ones? ________________with fluoride Yes / No If the teenager is not taking a vitamin, does your water supply contain fluoride? Yes / No Is the teenager allergic to any food or drinks?___________________________________ Social History: Does the teenager drink alcohol? Yes / No Type Quantity Frequency Duration Beer__________________________________ Wine__________________________________ Liquor_________________________________ Is the teenager following any special diet ? Yes / No How compliant is he/she to this special diet?____________________________________ Over the past month, has the teenager observed any changes in his/her dietary intake? Yes / No What type of milk does the teenager drink? Whole 2% 1% Skim No milk How many ounces of milk per day?____________________________________________ How many meals does the teenager eat during the day?_____________________________ Does the teenager skip meals? Yes / No If yes, which ones and why?_________________ How many snacks does the teenager eat during the day?__________________ How many meals away from home does the teenager eat every day? Which meals?__________ Does the teenager avoid any specific foods such as milk or meats?________________________ Is the teenager physically active? How often and what type of exercise does he/she participate in?____________________________________________ If the teenager has diabetes, does he/she self-monitor blood glucose levels? (When?)________ Review of Systems: General:__________________________________________________________ Skin:____________________________Hair:____________Nails:____________ Head:____________________________________________________________ Eyes: ____________________________________________________________ Mouth: ___________________________________________________________ GI/Abdomen: ______________________________________________________ Cardiac: __________________________________________________________ Extremities: _______________________________________________________ Neurological: ______________________________________________________ Musculoskeletal: ____________________________________________________ Physical Examination: (Applies to infants, children and adolescents) General:__________________________________________________________ Skin:____________________________Hair:____________Nails:____________ Head:____________________________________________________________ Eyes: ____________________________________________________________ Mouth: ___________________________________________________________ GI/Abdomen: ______________________________________________________ Cardiac: __________________________________________________________ Extremities: _______________________________________________________ Neurological: ______________________________________________________ Musculoskeletal: ____________________________________________________ Height (Length):______(cm)Height for Age:____________(%ile) Current weight:_______(kg) Weight for Age:___________(%ile) Ideal Weight for height:_______(kg) Ideal height for age:_______(cm) If weight change? (days, weeks or months)__________ Head circumference (cm): (%ile)______(For children < 3 years old- use growth chart) %Weight for Height:______________ Interpretation:_________________ %Height for Age:_______________ Interpretation:__________________ Laboratory Evaluation: Serum Albumin:_________________ Significance:_______________________________________________________ Serum Transferrin:___________________ Significance: _______________________________________________________ Serum Glucose (normal = 70 - 1 10 mg/dl))____________________ Significance: _______________________________________________________ Hematocrit and Hemoglobin ____________________ Significance: _______________________________________________________ Serum Cholesterol:_______________________ Significance: _______________________________________________________ Serum Triglycerides:______________________ Significance: _______________________________________________________ Other relevant lab data:
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