DIETITIAN INTERNSHIP MODEL REPORT
Dietitian Internship is done on final UG & PG Students those who are pursuing a degree in Nutrition and Dietetics & Food science and Nutrition & Food Service Management and also nutrition related studies.
NUTRITIONAL ASSESSMENT
Name:
Age/Sex:
Marital Status:
Height:
Weight:
BMI:
BMR:
Do you have any medical problems?
Hypertension: CVD:
Thyroid: Asthma:
Diabetes: Kidney Disease:
Osteoporosis/Arthritis: Menstrual cycle:
Digestive Problems: Anemia:
Family History:
Food Allergy:
Slow/Quick eater:
Are you vegetarian/non – veg/ Ovo/lacto:
Profession:
Are you a Sedentary/Moderate/Heavy Worker?
Who cooks at home
While eating involve in any activities:
Do you face hunger pangs?
What kind of oil should you use while cooking?
Likes:
Dislikes:
Sweet
Do you have any stress, professional /personal?
Is it mild/moderate/heavy stress:
What are the activities you do when you are stressed?
Mood Swings:
Bedtime/Wake up time: Quite/Disturb:
Water:
Non Veg – Egg: Sea Food: Poultry: Meat:
Green Leafy Veg: Sweets/Chocolates:
Roots & Tubers: Fruits:
Other Vegetables: Coconut (Dry/Fresh):
Dry fruits & Nuts: Milk and Milk Products:
Bakery Products: (butter, cream, ghee, cheese, paneer)
Junk foods(pizza burgers) Chats/Snacks:
Jams & Sauce: Beverages: Tea/coffee/Green tea
Alcohol/smoking/tobacco Aerated/Packaged/Bottled drinks:
Eating Out:
Early Morning:
Breakfast:
Mid – Morning
Lunch:
Evening:
Dinner:
Bed – Time
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