Cornell GI Metabolic & Bariatric surgery Program

Nutrition aSsessment

Name:______Date:______Surgeon:______(Please Circle:) Gastric Bypass / BPD-DS / Band / Sleeve Gastrectomy

Height:______Weight:______Desired Goal Weight______

Heaviest Weight and When______Lowest Weight (Since 21) ______

Childhood Weight (circle): Under Average Over

What are your goals for your nutritionist visit today?______

What makes it difficult for you to lose weight? ______

History of Anorexia/Bulimia?______History of Binge Eating?______

Weight Loss Program
/
Dates
/ How long on this? / How much lost? / MD/RD Supervised?
WeightWatchers
Nutrisystem
Jenny Craig
Atkins
Optifast /Medifast
Hospital Program / Spa
Prescription Meds
Exercise Programs
“Slimfast” /other Shakes
Nutritionists
Others, or on your own

Please check off appropriate box:

 Sleep Apnea Diabetes (how long? ____)  High Cholesterol  Hypertension

 Arthritis  Heart Disease  PCOS  Other______

Is there a family history of obesity or any of the above chronic diseases? If so, which ones?______

Are you presently doing any physical activity or exercise? If so, what is your regimen? ______

Please list food allergies and/or intolerances: ______I have good teeth and NO difficulty chewing food  Agree  Do NOT Agree

Please list medications / Vitamins / Minerals / Supplements / Herbs:______

______

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Nutrition aSsessment: page 2

How many times per week do you eat fast foods? ______

How many times per week do you dine out? ______

How many times per week do you eat fried food? ______

Do you add butter, margarine, salad dressing, oil, or mayonnaise to your food? (please circle)

How often do you eat sweets (circle- cookies, cake, candy, ice cream, chocolate)? _____ times /wk

Which of the following beverages do you drink?  water  seltzer  juice  regular soda  diet soda  other diet drinks  fruit drinks  whole milk  skim milk  low fat milk  soy milk chocolate milk coffee  tea  iced tea  other: ______

How often do you consume alcohol? ______Which type(s)? ______

Do you smoke? _____ About how many (pls circle- cigarettes, cigars, pipes ) per week?______

About how many hours of sleep do you get each night? ____ to ____ hours

Do you feel you crave the following foods:

 rice  pasta  bread  cereal  potatoes

Do you eat fruits and vegetables every day?  Yes  No

Do you eat cheese or yogurt everyday?  Yes  No

Do you eat (pls circle) beef, veal, pork, lamb, goat, chicken, turkey, fish, tofu, beans, eggs, nuts?

Do you eat at least one of these every day?  Yes  No. Which is your favorite? ______

What (“nutrient”) do these foods have in common? ______

What is the first thing that you eat or drink each day?

Do you eat Breakfast? If so, what?

What do you usually eat for lunch (if anything)?

What do you usually eat for dinner (if anything)?

What do you eat besides your meals? Snacks? What time(s) of day?