Nutritional Assessment Form
Patient’s Name: Age:
Height: Diagnosis:
Weight: Body Mass Index:
Patient’s History:
Medical History:
Vegetarian / Non vegetarian:
Food Allergy:
Lifestyle: Sedentary/ Moderate/ Active
Do you drink alcohol, Yes or No?
Do you smoke, Yes or No?
How often do you eat from outside/restaurants? Daily OR Weekly OR Fortnightly OR Monthly
Insulin Prescribed: Yes/ No
Biochemical Parameters:
HbA1c [%]:
Fasting Blood Glucose [mg/dl]:
Post-prandial Blood Glucose [mg/dl]:
Any other:
DIET PLAN:
Early Morning:
Breakfast:
Mid-Morning:
Lunch:
Evening Meal:
Dinner:
DIETARY GUIDELINES FOR DIABETES
1. First and foremost, the step is to achieve and maintain body weight.
2. People with diabetes and those at risk should avoid sugar-sweetened foods and minimize consuming
foods with added sugar that can displace healthier, more nutrient-dense food choices.
3. Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high in fiber,
including vegetables, fruits, legumes, whole grains, as well as dairy products.
4. Replace regular sugar with Non-nutritive sweeteners like Sucralose (Splenda®), Stevia, Saccharine
(Sugar Twin®, Sweet ‘N Low®), Aspartame (Equal®, NutraSweet®), and Neotame.
5. Patients with DM should consume 20 to 35 g of fiber from raw vegetables and unprocessed grains.
6. Use healthy oils like soyabean, canola, olive, rice bran and mustard oil for cooking. Use minimal
quantity. Preferably non stick utensils. Keep changing the oil every couple of months.
7. Eat one or more good sources of omega-3 fats every day—fatty fish, walnuts, soybean oil,
groundnut, flax seeds, chia seeds, etc.
8. Good sources of lean animal protein & Plant protein sources should be encouraged in the diet in
every meal.
9. Refraining from drinking excessive amounts of alcohol or keeping intake to less than one drink a day
for women or two drinks a day for men or 120ml per week.
10. Daily Physical activity is the second main goal to manage diabetes. According to the American
Diabetic Association (ADA), most adults with type 2 diabetes should engage in 150 min or more of
moderate-to-vigorous intensity exercise per week, spread over at least 3 days/week.
11. Prolonged sitting should be interrupted every 30 min for blood glucose benefits.
CHOOSE NOT TO CHOOSE
Cereals Complex carbs: whole wheat maida, corn, white bread,
flour, ragi, bajra, jowar, sugars, pasta, bakery items,
multigrain bread, brown rice, biscuits, etc
oats, quinoa, etc
Milk & its Products Low-fat milk, curd, low-fat Cheese, khoa, full-fat milk,
paneer, soya milk, nut milk cream, milk-based desserts
Fruits Have 1-2 servings of fruits in a mango, banana, chikoo, grapes,
day [100-150g]. fruits like custard apple
papaya, apple, melons,
strawberry, pears, oranges,
guava, etc are recommended
Vegetables Have 4-5 servings of starchy vegetables like potato,
vegetables in a day. all green yam, beetroot, turnip, butternut
leafy and other vegetables in squash, corn
abundance
Pulses All whole pulses like rajma, -
chana, chole, vatana, matki,
usual & dal like moong, chana,
arhar, lentil sprouts, soybean,
etc
Fat Unsaturated fat sources like Cream, cheese, butter, full
nuts, oil seeds & vegetable oil cream milk, Coconut oil, ghee,
are recommended in restricted margarine, and palm kernel oil.
quantities. Almonds, walnuts,
flaxseeds, chia seeds,