Sage Dietetic Internship - NCP Form

Patient: T.F. Referred for: weight loss/health eating

NUTRITION ASSESSMENT
Food and Nutrition Related History: Patient is !nhapp with c!rrent weight and is see"ing assistance with weight loss and health
eating. Patient reports #efore pregnanc two ears ago$ weight was at %&'l#( is now %)*l#. Patient wo!ld li"e to achie+e goal weight of
%%&l#. Patient feels fi#er inta"e is low and wo!ld li"e to learn some health$ satisfing snac" options and portion control. Patient reports
#eing a fast eater( is gi+en ,)min l!nch #rea" at wor" #!t !s!all finishes within -)min. Patient also admits to eating o!t with famil %-
.//wee"$ !s!all at a local diner. Patient tpicall chooses grilled cheese with so!p or splits meal with mother. Patient does not
c!rrentl participate in an phsical acti+it.
Food Recall:
0rea"fast: either % waffles with sr!p or -/% c!p oatmeal with mil" and raisins$ % c!ps coffee with creamer and - p"g s!gar
1!nch: ma #e a P0 2 3 sandwich with chips$ lefto+ers from pre+io!s night4s dinner$ salad with +eggies and dressing$ or sometimes a
catered l!nch at the office( !s!all chic"en$ sides$ salad$ .% o!nce water #ottle
Dinner: some tpe of meat/pot/+eggie or pasta with sa!ce and salad$ low-fat-mil"
Snac": %-. 5reos with low-fat mil"
Food Sensitivities: Beef
Food Allergies: Clas
Ant!ro"oetri# Measureents
6ge: ,% 7ender:
Female
8t: )49: ;99:< =t: %)*l# ;--*"g<
=t 8/: %&'l# ;%&-%<
=t change: %.> weight gain
0?I: ,-.) ;5#ese<
Bioedi#al $ata% Medi#al Tests & 'ro#edures
1a#s/Dat
e
6l#!min 7l!cos
e
8#6-C 0@N Creat NaA BA 8g# 8ct ?CC 5ther
n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a
Medi#al $iagnosis('MH(Relevant Conditions: #orderline dia#etic$ sleep apnea$ di+ertic!litis$ pol cstic o+aries$ fi#romalgia
Fa H): father: dia#etes$ hperlipidiemia$ hpertension( mother: throid
'ertinent Medi#ations: m!lti-+itamin dail$ inhaler as needed$ am#ien as needed
S*in status: X Intact Press!re @lcer/Non-healing wo!nd
Comments:
'!ysi#al Assessent: n/a
Estiated Nutritional Needs Based on Co"arative Standards:
Calories: ?ifflin St. 3eor / -..
%,&&-%*&&"cal/da
Protein: &.D--.&g/"g/da
',---*g/da
Fl!id: .&ml/"g/da
.,%&ml/da
Diet 5rder:
Reg!lar
Feeding 6#ilit
X Independent
1imited 6ssistance
E/tensi+e/Total 6ssistance
N/6
5ral Pro#lems
Chewing Pro#lem
Swallowing Pro#lem
?o!th Pain
X None of the 6#o+e
Inta"e
X 7ood ;F *)><
Fair ;appro/. )&><
Poor ;G)&><
?inimal H ;G%)><
NP5
No N!tritional Diagnosis at this time X Proceed to N!trition Diagnosis 0elow
NUTRITION $IA+NOSIS
P ;pro#lem< 5+erweight/5#esit related to: E ;Etiolog< e/cessi+e energ inta"e and
lac" of phsical acti+it as e+idenced #:
S ;Signs 2 Smptoms<: patient reports of
!ncertaint regarding n!trition-related
recommendations and 0?I of ,-.)
INTER,ENTION
N!trition Prescription: recommend #alanced deficit meal plan: negati+e energ #alance of )&&--&&& "cal/da to pro+ide -,&&-
-*&&"cal/da
Food or N!trient Deli+er:
?eals and Snac"s: well #alanced$ health meals and snac"s
thro!gho!t the da to pro+ide appro/ -)&&"cal
N!trition ed!cation:
Content/6pplication: ?editerranean diet$ sample -)&&"cal men!s$
health -&&-calorie snac"s$ was to increase fi#er ;whole grains$
fr!its$ +egeta#les<$ portion siIing !sing mplate$ shopping/coo"ing
tips for weight management$ choosing health options when
eating o!t$ mindf!l eating tips$ incorporating phsical acti+it into
dail ro!tine
N!trition Co!nseling: Cogniti+e-0eha+ioral Theor$ 8ealth 0elief Coordination of Care ;refer to<: n/a
%&-. S7S DI
?odel
7oal;s<: patient to achie+e safe weight loss of --%l# per wee" on well #alanced calorie controlled diet plan
MONITORIN+ & E,A-UATION
Indicators:
=eight
Criteria:
--%l# weight loss per wee"
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InternKs Signat!re Date PreceptorKs Signat!re
Date
%&-. S7S DI