Nutritional Assessment
Submit the form below to get started with
Roots Food Group!
First Name*
Last Name*
Phone Number*
Email
Gender*
Date of Birth*
Client Identification Number*
Medi-Cal Provider*
Address*
City*
State*
Zip Code*
Consent*
Does the person being referred to the program consent to providing answers to the following questions?
Yes
No
*All meal bundles are regular in texture and contain dairy, gluten/wheat, eggs, tree nuts (coconut), and sesame.
Conditions/Diseases*
Do you have any of the following conditions/diseases affected by nutrition?
Diabetes
Gestational Diabetes
Chronic Kidney Disease (CKD)
Chronic Lung Disorder
Cardiovascular Disorders
Congestive Heart Failure
Stroke
Hypertension
Chronic or Disabling Mental/Behavioral Health Disorders
High Risk of Perinatal Conditions
HIV
Cancer
Other
Other Conditions/Disease
If you answered other to conditions/diseases affected by nutrition, please state your condition here.
Appetite Rating*
How would you rate your appetite during the last month?
-
Poor
Fair
Good
Other
Appetite Rating-Other
If you marked other for appetite rating, please explain.
Chewing/Swallowing*
Do you have any difficulty chewing or swallowing?
Yes
No
Yes-Difficulty Chewing/Swallowing
If you answered yes, you have difficulty chewing or swallowing, please explain.
Previous Breakfast*
What did you eat for breakfast yesterday?
Previous Lunch*
What did you eat for lunch yesterday?
Previous Dinner*
What did you eat for dinner yesterday?
Previous Snacks*
What snacks did you eat yesterday?
Previous Beverages*
What beverages did you drink yesterday?
Dietary Limitations*
Dietary Limitations (Allergies, cultural/religious preferences):
Average Weight*
What has been your average weight over the last year?
Weight Changes*
Have you had any weight changes (loss or gain)?
Yes
No
Weight Change-Yes
If you answered yes, you have had recent weight changes, please explain here.
Height*
Please provide your height in feet and inches.
Cooking*
Please name who cooks at home (you or other)
Fruits*
How many fruits do you eat per day?
Starchy Vegetables*
How many starchy vegetables do you eat per day? Examples include broccoli, bell peppers, onions, tomatoes?
Proteins*
What types of proteins do you eat? (Select all that apply)
Freezer*
Do you own a freezer?
Yes
No
Nutritional Counseling*
Are you interested in an additional nutrition consult with a registered dietitian at Roots Food Group?
Yes
No
Additional Details
Is there anything else you would like to share with us about your nutrition intake?
Provide/Confirm Shipping Address
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