NURS 225: Nutritional Self-Assessment
Name________________________________ Date_________________
Part 1
Subjective information. Answer each question:
1. Family History: (check all that apply)
___ Diabetes
___ Heart Disease
___ Weight Problems
____Cancer
____ High Cholesterol ____ Hypertension
____ Other____________________________ None _______________
How could these disorders affect your diet? __________________________
2. Culture: How does your ethnic culture or race affect your nutritional choices?
______________________________________________________________
3. Activity Level:
____Never ____ Occasionally ____1-2 times/week ____3-4 times/week
____ 5 or more days/week
Describe:
4. BMI Calculation:
_____ Height _____ Weight _____ BMI
Show calculation to obtain BMI:
Analysis of BMI calculation:
Part 2:
Barriers to Healthy Living: Answer each question below: Answer agree if this is a barrier that
applies to you or disagree if it is not a barrier.
Provide an explanation of your answer choice.
I do not have time to prepare healthy foods
Explain:
I find myself snacking on nhealthy&oods while studying
Explain:
I do not like the taste of healthy foods
Explain:
I have problems making healthy food my family will eat
Explain:
I eat when I feel sad/depressed/stressed/happy/or other emotion
Explain:
I get ad!t myself for not making healthier food choices
Explain:
I often eat past the time of feeling µll…xplain:
I often have powerful cravings for nhealthy&oods
Explain:
I do not have time to exercise
Explain:
I feel self-conscious when I exercise
Explain:
Part 3:
Two-day food recall: Write down all foods consumed for two full days.
Agree
Disagree
Day One
Day Two
Breakfast:
Breakfast:
Lunch:
Lunch:
Dinner:
Dinner:
Snacks:
Snacks:
Nutrition: Find the nutritional values for the nutrients below for each day:
Your Recommend Daily
Allowance based on
weight/height/activity
level
Day One
Day Two
Protein
B:
L:
D:
S:
B:
L:
D:
S:
Carbohydrates
B:
L:
D:
S:
B:
L:
D:
S:
Fat
B:
L:
D:
S:
B:
L:
D:
S:
Fiber
B:
L:
D:
S:
B:
L:
D:
S:
Vitamin C
B:
L:
D:
S:
B:
L:
D:
S:
Nutrient
Iron
B:
L:
D:
S:
B:
L:
D:
S:
Cholesterol
B:
L:
D:
S:
B:
L:
D:
S:
Part 4:
Answer each question based on your food recall
1. Based on your subjective data, barriers, and nutritional analysis, what changes should
you make to your current diet? (Support your answer with at least one reference)
2. Provide one SMART goal (Specific, measurable, achievable, realistic, timed) and two
strategies to help you obtain that goal.
3. Reflection: What did you learn from this assignment regarding your diet and health in
regard to your dietary habits?

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