無料栄養評価フォーム

管理栄養士・栄養士向けの包括的な印刷可能栄養評価フォームです。身体計測、24時間食事回想、食物摂取頻度調査票、臨床メモを含みます。無料でPDFとして印刷または保存できます。

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Nutrition Assessment Form

Client:

Date:

Practitioner:

Assessment type:

Anthropometric Measurements

Height (cm)

Weight (kg)

BMI

Waist (cm)

Hip (cm)

Waist:Hip ratio

Body fat %

Muscle mass (kg)

24-Hour Diet Recall

Time	Food and drink consumed	Amount / portion	Where eaten	Notes

Food Frequency Questionnaire (FFQ)

For each food, circle or tick the frequency that best describes your usual intake over the past 3 months.

Food / Drink	Never	Rarely	1-2x/week	3-4x/week	5-6x/week	Daily	Portion size
Grains and starches
White bread/rolls
Wholegrain bread
Rice
Pasta/noodles
Oats/porridge
Breakfast cereals
Crackers/crispbreads
Vegetables
Leafy greens (spinach, kale)
Cruciferous veg (broccoli, cauliflower)
Root vegetables (carrots, sweet potato)
Tomatoes/capsicum/zucchini
Legumes (lentils, beans, chickpeas)
Salad vegetables
Fruit
Berries
Citrus fruit
Tropical fruit (banana, mango)
Apples/pears
Stone fruit
Fruit juice (100%)
Protein foods
Red meat (beef, lamb)
Processed meat (sausages, deli)
Poultry (chicken, turkey)
Fish (fresh or frozen)
Canned fish (tuna, salmon)
Eggs
Tofu/tempeh/edamame
Dairy and alternatives
Milk or milk alternative
Cheese
Yoghurt
Cream/butter
Fats and snacks
Nuts and seeds
Avocado
Oils (olive, vegetable)
Chips/crisps
Chocolate/confectionery
Cakes/biscuits/pastries
Drinks
Water (glasses/day)
Tea or coffee (with milk)
Soft drinks/energy drinks
Alcohol

Clinical Notes

Current nutrition-related concerns:

Relevant medical diagnoses:

Current medications (affecting nutrition):

GI symptoms / digestion notes:

Blood glucose / lipid results (if available):

Practitioner observations:

Nutrition Goals and Priorities

Priority areas for this client:

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How to conduct a nutrition assessment

Start by recording anthropometric measurements at the beginning of the consultation. Height, weight, BMI, and waist circumference are the minimum for most adult assessments. Body fat percentage and muscle mass are useful additions for clients with fitness-related goals or for tracking body composition changes over time.

The 24-hour diet recall is best conducted using the multiple-pass method: first ask the client to list everything they ate and drank yesterday without prompting, then go back through each occasion and probe for details about portion sizes, preparation methods and any additions. This approach produces more complete and accurate data than a single open-ended question.

The food frequency questionnaire section captures habitual intake patterns that a single day's recall cannot show. Ask clients to think about the past three months rather than last week to give a more representative picture of their diet.

Components of a complete nutrition assessment

Anthropometric data: height, weight, BMI, waist circumference, body composition.
Biochemical data: relevant blood results including lipids, glucose, iron, vitamin D and B12 where available.
Clinical signs: physical indicators of nutritional deficiency such as hair, skin and nail changes.
Dietary intake: 24-hour recall, food frequency questionnaire, and usual meal pattern.
Medication review: current medications and supplements that affect nutritional status.
Environmental and social factors: food access, cooking skills, household situation, financial constraints.

Frequently asked questions

What is a nutrition assessment form?

A nutrition assessment form is a clinical tool used by dietitians and nutritionists to evaluate a client's current nutritional status. It typically combines anthropometric measurements (height, weight, BMI), a 24-hour diet recall, a food frequency questionnaire (FFQ), clinical observations, and relevant medical history. Together these components give a comprehensive picture of nutritional intake and risk.

What is a food frequency questionnaire (FFQ)?

A food frequency questionnaire is a structured tool that asks clients how often they typically consume specific foods or food groups over a set period, usually the past three months. It differs from a diet recall in that it captures habitual intake patterns rather than a single day's eating. FFQs are particularly useful for identifying whether clients are meeting recommendations for key food groups like vegetables, protein foods, dairy and whole grains.

Who should use a nutrition assessment form?

Nutrition assessment forms are primarily used by registered dietitians, accredited practising dietitians, and nutritionists in clinical and private practice settings. Personal trainers and health coaches can also use simplified versions when nutrition guidance falls within their scope of practice. For clients with complex medical conditions, a full clinical assessment by a registered dietitian is recommended.

When should I conduct a nutrition assessment?

A full nutrition assessment is typically carried out at a new client's first consultation, and then repeated annually or when significant health changes occur. A shorter review can be done at regular follow-up appointments to track progress. The 24-hour diet recall section is particularly useful for ongoing monitoring between full assessments.

How does this nutrition assessment form differ from an intake form?

An intake form collects background information (personal details, health history, goals, preferences) before the first consultation. A nutrition assessment form goes deeper, combining clinical measurements, a structured dietary recall, and a food frequency questionnaire to evaluate nutritional status in detail. Many practitioners use both: the intake form for background and the assessment form for clinical evaluation.

Can I use this form for paediatric or elderly clients?

This form is designed for adult clients. For paediatric nutrition assessments, additional fields for growth charts, developmental milestones, and parental dietary patterns are needed. For elderly clients, consider adding screens for malnutrition risk (such as the MNA or MUST tools) and questions about chewing or swallowing difficulties. Our Paediatric Calorie Calculator and Percent Weight Change Calculator may be useful adjuncts.