7

DICAL NUTRITION THERAPY ASSESSMENT

DATE:

PLEASE COMPLETE THE FOLLOWING SUESTIONS..

Name
Phone: (home) Physician:

DOB:

_Ag.:

_
Yes
No

(*o.D

(Ce11)

Can we leave a message?

Have you checked i:rsurance coverage for this

program? Yes No

Have you ever received diet counseling? Do you currently foliow

&' Yes If yes, with who and when: a special mealplan?@ Yes If yes, describe: G *o
What weight loss methods worked for you?

Have you ever tried to lose weight?

\N[

List any food allergies'

ND

Any other special dietary needs

NI\
SP[Y')
Sou"t,
Snacks

What time do you eat on workdays? Breakfast CiCf What time do you eat on weekends?

fVf Lunch Lunch

tim.,
N l)

Dinner

Breakfast

Dinner

Describe any obstacles ttrat prevent you from eating on Who does the cookilg?

Who does the grocery shopping?

How often do you eat at restauruots How often do you order take

C ti*e per week/month Type: !

Fast

Food

n Sit-dow:r

Buffet

o,rtZ (rl time per week / month .1r3f (<rrGPPle 5 Sweetened drinks ( soda, juice) _ How many times a day do you have: Sweets Fruit L ' Vegetables _ Howmuchmiikdo you drink a day?: <' 14 C. What are your two favorite foods
How wouid you describe your portions? Smal1 What changes,

Large

Does mood / skess effect your

eatrnez@

No

if

any, do you

thilk you need to make in your

eating habits/diet?

Anything else you think we should lsrow about your eating habits?
I

uvv

lou-d g lucoiB

If you did not bring in a food recall record, please turn oyer and fill in the boxes provided to give us an idea o f the foods you eat on a typical day. Ifyoir have a completed food recall record with you, you can stop here

STOP EERE

TITE FOLLOWING WILL BE COMPLETED

BYTIIE DIETITIAN

Ht, 5)

l'r *,, z)b stmcn:.t#;"I"J*]J;;

Recent Weight

change? n ')

Reason for weight change:

Type 2(non-insulin r-,""" CC,t/) Type t, 6r "@ List Diabetes -.ar' (11 li rr de 4ir
Date of

Diag"ori., f Z,,/

Type Z(on

insulin),

Gestational DM

Other Health Conditions Exercise history:

Signature:

nate: Cl

lVlt'

IYIET'IUAL N U'I'RI'I'ION THERAPY

INITIAL YISIT EDUCATION RECORI)

By the conclusion of the session, the patient will:

Review food intake and discuss chanses needed to Discuss preferred method of meal planning
State ways to reduce sodium /fat/ cholesterol intake Discuss benefits of

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healthy weight and BG control

Select behavior change goals. (See chart on back)

Discuss obstacles which would hinder progress toward goals,

Meal Planning method:

/caruotyi.ate

General suidelines usine Mv Plate. intake uuia {

tr

on

3( )( )

,' .,r .r

tr - General guidelines using plate method / portion sizes calories (General guidelines with emphasis on carb grams or servings per meal

Insulin to Carbohydrate Ratio

/'\ II

Otner:

,Caibohiaiaie;r "i .1.r. : ;:8, r .:4:, . , iservtnss '-' ;,

Breakfast
Snack
2_, .)

L\t

'\

7)

Lunch
Snack

4t
.-\ _,
rL-

L-

Dinner
Snack

t,
' !

-7-

Daily Total

lL l-'
ofood labels oother:

lnstruction methods used:

').food

replicas (discrssion

\cl Oi

IC
_\\

Written materials provided

y'carboh ;Hrl

tt*llg
,r',

bookret x

.;illtLlJ

i"\,),,*

pamph, et

o food record forms

uuu,U

o meal plan

MEDICAL NUTRITION THERAPY TNITIAL VISIT EDUCATION RECORD

BMI Categories: Normal:18.5 -24.9
Overweight = 25 -29.9 Obesity = >30

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Goat weigttr, Vrl

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Dateset:

Ctltt
_

lt3
servings

o l. I will

eat 3 meals and

a 2, I will eat

of vegetables each day.

(:.

I wilt count my carbohydrate servings or carbohydrate grams for meals and snacks. I

!+,

*itt

eat

breakfast@-J'.u.v

aur.

o 5. I will read food labels u 6. I will use measuring cups to determine appropriate portion sizes. o 7. I

will

for

minutes on

days a week to increase physical activiry.

o8.

Level of motivation to make behavior changes: Level of comprehension of meal planning

excellent

good Xfuit

tr poor

! Sooa u fair tr poor -1U"*, Follow up plan: MNT appointment scheduled: aEglgd=gd o Declined turther MNT follow up. / (? 'tcu,,Diabetes IZO( t3 tfCf t Vf ;i 1in Day by Day DSME care RD as needed f,enroued method:
o excellent
o Other:

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