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Telemedicine Consent
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Reason for Referral:
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Type of Visit
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General Assessment
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Weight Trend
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BMI (calculated)
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Ideal body weight
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Usual body weight
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Goal weight
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Adjusted Body Weight
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Nutrition/Social History
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Previous visit with Dietitian?
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Current Problems
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Vitamins/Herbals
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Food Allergies/Intolerance
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Alcohol
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Tobacco
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Drugs
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Exercise
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Minutes of exercise per session
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Current Medications
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Current Laboratory Values
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Diagnosis
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Nutrition Diagnosis
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Status of nutrition diagnosis
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Nutrition Prescription
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Nutrition Intervention
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Education Provided
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Goals
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Goals
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Progress towards goals
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Patient understanding appears
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Patient adherence is expected as
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Plan
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Monitoring and Evaluation
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FOLLOW UP PLAN
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PCP
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Smoking Cessation Counseling
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Nicole's Signature
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Nutrition Time Spent
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