Nutritional Assessment

Nutrition Assessment/Consultation Disclosure Statement: By completing this assessment, you are consenting to allow Roots Food Group to use your information solely for the purpose of qualifying you to receive a medically tailored meal prescription under the CalAIM community supports program.
Please provide your height in feet and inches.
Please provide your height in feet and inches.
Have you had any weight changes (loss or gain)?
If you answered yes, you have had recent weight changes, please explain here.
Do you have any of the following conditions/diseases affected by nutrition?
If you answered yes, you have been discharged within 6 months, please explain.
How would you rate your appetite during the last month?
If you marked other for appetite rating, please explain.
Do you have any difficulty chewing or swallowing?
If you answered yes, you have difficulty chewing or swallowing, please explain.
If yes please explain
What did you eat for breakfast yesterday?
What did you eat for lunch yesterday?
What did you eat for dinner yesterday?
What snacks did you eat yesterday?
Please name who cooks at home (Self, Parents, Spouse, Caregiver, etc.)
How many fruits do you eat per day?
How many non-starchy vegetables do you eat per day? Examples include broccoli, bell peppers, onions, tomatoes?
What types of proteins do you eat? (Select all that apply)
Do you own a freezer?
Is there anything else you would like to share with us about your nutrition intake?
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