Celiac Disease Nutrition Assessment Form
Patient Information
Full Name
Date of Birth
Age
Sex
Female
Male
Other
Contact Information
Medical History
Date of Celiac Disease Diagnosis
Current Symptoms
Other Medical Conditions
Medications/Supplements
Anthropometric Measurements
Height (cm)
Weight (kg)
BMI
Recent Weight Changes
Diet History
Typical Daily Food Intake
Understanding of Gluten-Free Diet
Compliance with Gluten-Free Diet
Always
Mostly
Sometimes
Rarely
Incidents of Gluten Exposure
Other Dietary Restrictions/Preferences
Meal Preparation/Shopping Challenges
Biochemical Data
Recent Lab Results (iron, vitamins, etc.)
Nutrition Assessment Summary
Assessment Notes
Nutrition Intervention/Recommendations
Follow-Up Plan