A six-dimension nutritional status assessment — dietary diversity, macronutrient balance, micronutrient adequacy, hydration, meal regularity and portion control — scored on 1–5 statements and turned into a printable AI PDF report with practical dietary next steps.
Quick answer
A nutritional status assessment scores six dimensions — dietary diversity, macronutrient balance, micronutrient adequacy, hydration status, meal regularity and portion control — on 1–5 statements, and produces a personal AI PDF report showing which eating pattern to improve first.
Disclaimer: this page and its AI report are for self-reflection and process reference only. They do not constitute medical, psychological, financial, legal or safety advice. Consult a qualified clinician before making care decisions.
Methodology: items are a structural adaptation of widely used clinical frameworks, not an official validated instrument; scores are indicative, not diagnostic.
“Eating healthy” is six different habits, and most people are strong in some and weak in others. This assessment scores each one separately: variety across food groups, carb-protein-fat balance, vitamin and mineral coverage, daily hydration, regular meal timing and portion size. The AI report ranks the six and suggests two or three concrete food swaps rather than a generic diet plan.
Sample form, AI PDF report and AI consultant — fill the form to unlock all three.
Everything you need to run this template.
From copy to deliverable in four steps.
Copy the form and its scoring, report and branding settings into your FormLM workspace — free.
Adjust fields, options and consent language to match your clinic workflow.
Send the link or QR; every response is captured automatically.
Open the personalized AI PDF report and share it with the patient or the chart.
Pick your role — see how it fits your clinic workflow.
Start consultations from a scored baseline.
Track cohort nutrition quality over time.
Know whether variety, balance or routine is the gap.
What makes this template work as a professional clinical deliverable.
A preview of real statements respondents rate — the full version scores each answer 1–5 across six dimensions and generates a personalized, printable AI PDF report per respondent.
