Prenatal Nutrition Assessment Form
Personal Information
Name
Age
Date of Birth
Contact Number
Address
Pregnancy Information
Gestational Age (weeks)
Estimated Due Date
Number of Pregnancies
Parity
Anthropometric Data
Pre-pregnancy Weight (kg)
Current Weight (kg)
Height (cm)
Medical History
Relevant Medical Conditions
Current Medications
Food Allergies
Dietary Assessment
Describe Usual Dietary Pattern
Food Intolerances
Supplements Currently Taken
Lifestyle Factors
Smoking
No
Yes
Alcohol Consumption
No
Yes
Physical Activity Level
Notes/Recommendations