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

(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:
Is your child allergic to any food or drinks?     Yes / No     Do they get a rash or exema     Yes / No
If yes, allergic reaction to what? ______________________________________

Does your child take any vitamins / minerals or food supplements?     Yes / No
If yes, which ones?____________________________________with fluoride Yes / No
If your child is not taking a vitamin, does your water supply contain fluoride? Yes / No

Social History:
What type of milk are you feeding your child? _____________# ounces drank/day?______ If you feed your child formula, how much do you give and how much water do you add?

What else does your child drink during the day?     Ice tea     Soda     Diet soda     Kool aid     Juice Water     Hawaiian punch      other_______

Is your child put to bed with a bottle?     Yes / No

If your child is eating foods, when did you start to introduce solid foods into their diet? ___________________

How many meals does your child eat during the day?________________

How many snacks does your child eat during the day?________________

Does your child usually eat the food that is prepared for the family?    Yes / No

Does your child avoid any specific foods such as milk or meats? Yes / No
If yes, which ones?______________________________

Does your child chew on any:     Dirt     Clay     Paint chips     Woodwork     Ice Plaster     Newspaper

How old is your house? Do you have lead pipes? Yes/No Has the water been tested for lead? Yes/No

Review of Systems:

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:_________________

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: