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Telemedicine Consent
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Reason for Referral
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Pre-Op Visit #
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Nutrition Assessment
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Recent changes to health history?
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Motivation for Weight loss/Bariatric surgery
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Support System
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Weight History
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Previous weight loss attempts?
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Current Anthropometrics
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Ideal Body Weight
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Current Excess Body Weight
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Weight loss since last visit
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PATIENT HISTORIES
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Physician Diagnosed Comorbidities
• • •
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Additional Pertinent Medical History
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Has the patient reported a current or past diagnosis of eating disorder?
• • •
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Has the patient reported any emotional eating-related behaviors?
• • •
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Gastrointestinal Function
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Social History
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Sleep Quality
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Stress Level(s)
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Physical Activity
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Food Allergies
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Food Intolerances
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Food and Beverage Intake
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Caffeine Intake
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Carbonated Beverage Intake
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Alcohol Intake
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Tobacco History
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Recreational Drug Use
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Medication History
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Over-the-Counter Supplementation & Vitamins
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Nutrition Diagnosis
• • •
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Etiology; Signs/Symptoms
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Nutrition Intervention
• • •
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Education Topic
• • •
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Goals
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Education material(s) provided
• • •
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Expected Patient Understanding
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Expected Patient Compliance
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Monitoring/Evaluation
• • •
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Smoking Cessation Counseling
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Katia's Signature
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Time Spent
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