Nutrition SOAP note:

Subjective:
Client states that she was able to follow the pre-assessment guidelines; states no pre-existing medical conditions;
claims a family history of cancer and cardiac disease on her mothers side and diabetes on her fathers side; claims
that she is moderately active (running 6-10 miles nearly every day, doing yoga or similar activities every so often);
stated that she has no nutritional concerns but during the appointment expressed that she has been rejected for
plasma donation many times due to low hemoglobin levels (when asked client expressed a distaste for red meat) and
was also concerned when her BMD and T-score indicated she was osteopenic (when prompted client states she
regularly drinks a lot of milk); pts general appearance is normal; pt. reports no GI problems

Objective:
Anthropometric - Age: 20 yo. female, Height: 59.5 (176.5 cm); Weight: 186.5 # (84.8 kg)
Elbow Breath: 6.0 cm; Wrist Circumference: 17.5 cm; Frame Size: Medium; Knee Height: 59.1 cm;
Est. Stature: 168.8 cm; Waist: 39 in.(99.1 cm); Hip: 44 in. (111.8 cm); Ratio: .89 (High-risk); MAC: 29.1 cm;
Est. Weight: 75.4 kg IBW: 147.5 # (67.0 kg); %IBW: 126.4%; BMI: 27.2 (overweight); TSF: 41 mm;
TSF Percentile: >95th; Suprailium: 49 mm; Thigh: 49 mm; %BF: >40% (unhealthy -too high)
cAMA calculation: 14.43 cm; cAMA nomogram: 13.0 cm; cAMA percentile: <5th (wasted);
BIA (Tanita): 37.1% Fat; Est. BMD: .399 g/cm2; T-Score: -1.6 (osteopenia)

Biochemical Triglycerides: 114 mg/dL; Total Cholesterol: 159 mg/dL; LDLc: 90 mg/dL; HDLc: 46 mg/dL;
Blood Glucose: 86 (normal, fasting); Hemoglobin: 11.8 g/dL (low); Hematocrit: N/A

Clinical BP (Manual): 110/69; BP (Automatic): 105/64; Pulse: 79/minute

Dietary Est. Calorie Needs: 1878-2168 (1900-2200) kcals.; Average Calorie Intake: 1522 kcals.;
%Protein: 19% of daily kcals.; %Carbs: 42% of daily kcals.(low); %Fat: 41% of daily kcals. (high);
Nutrients to note (Below RDA or above 130% of the RDA): %Sodium: 131.7%; %Potassium: 54.5%;
%Magnesium: 75.5%; %Phosphorus: 177.7%; %Selenium: 170.9%; %Vitamin D: 26.7%;
%Vitamin E: 33.3%; %Vitamin K: 217.8%; %Folate: 50.5%; %Thiamin: 90.9%; %Riboflavin: 154.5%;
%Niacin: 92.9%; %Choline: 81.9%

Assessment:
Patient is not consuming enough calories for her activity level and is under the recommended servings for nearly all
food groups.
Patient demonstrated concern about iron levels and high T-score; found that she is Iron deficient and
Vitamin D deficient (affecting her calcium absorption).

Plan:
Intervention Provide My Plate My Wins Daily Checklist and explain/demonstrate (with current food
record) the importance of meeting daily recommended servings within food groups (this should remedy
most nutrient concerns as well as the low caloric intake); Provide recommendation for Vitamin D
supplement and being more active outdoors to boost calcium absorption and build bone mineral density;
Also provide Mayo clinics list of iron rich foods as well to be incorporated to the daily diet with a serving of Vitamin C
rich foods

Goals Become more conscious of calorie and food group intake to support activity level; boost iron stores; boost
calcium absorption; Have patient fill out Daily Checklist at least 2x a week for 3 weeks to consciously build a habit and
then on the 4th week fill out a 3-day food record (including supplement compliance) and return for follow-up.

Monitor/Reassess Will reassess the food record to see if positive change has taken place, will reassess
intervention tool and determine if it was effective for patient, will check hemoglobin levels as well as BMD and T-
score. If hemoglobin levels do not improve will provide a recommendation for iron supplement. Patient may
make a follow-up appointment sooner if needed.

Completed by:______________________________________ Date: ___________________