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: