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Diet recall
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Following any special diet plan?
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Meals per day?
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Who is in charge of preparing meals at home?
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Eating out? Type of restaurant and frequency.
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Tried to lose weight in the past?
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If yes, method used.
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Physical activity, limitations if any
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Turn on this switch Age/Gender will autopopulate
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Weight changes:
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Wt. goal:
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Food allergies:
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Foods avoided for other reasons:
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Chewing/swallowing difficulties
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Labs:
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Significant Labs:
• • •
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Others
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O.T.C. (herbs and supplements):
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Smoking
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Alcohol
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Substances:
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Weight assessment:
• • •
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Comments
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Labs in range/out of range
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Comments
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Nutrition: RD’s impression of patient’s diet
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Comments
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knowledge of nutrition based on prior education
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Comments
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EDUCATION FOCUS
• • •
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Resources provided:
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ESTIMATED ENERGY AND PROTEIN MAINTENANCE NEEDS:
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Motivation
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Importance of goal of diet changes
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Confidence goals can be achieved
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Obstacles to change:
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Barriers to learning:
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Participate in nutrition selfmanagement training
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Stage of change
• • •
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Desired measurable outcomes
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Patient's nutrition plan
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Provided RD contact info and schedule f/up in___
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Pull up Lab from the History
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