Wake up time: Breakfast:

Breakfast time: Nutrition Follow-up

Lunch: Progress Report

Lunch time : Demography Information

Snack: and Medical history
Name: Age: Date:
Snack time: Dinner :
Gender: Male or Female Last RD visit: Last MD visit:

Bed time:
DOB: Weight loss/gain: Drinks (oz/of water
BMI :a day): Blood pressure:

Signs and Symptoms:

Please circle
None
Vomiting Rapid heartbeat cravings Short of breath
Depression/ anxiety Cold extremities Cramps Fluid retention
Lack of interest Constant hunger Irritable indigestion
Lack of control Leg aches Moody Gas
Nausea Difficult sleeping Weakness Numbness

Others please state ________________________________________________________________

24 hour recall

New Laboratory Results & Supplementation

New Medication/ Supplement Yes or No
Please list ____________________________________________________________________________
Date of lab o A1C o LD o BU o Homocys o insulin
Results L N
o Glu o Cho o Trig o Creat o others
l
Goals
o Achieved to meet o Achieved first goal o Still working towards
objectives goal
Changes in diet prescription/ Comments
New Goals/Plans and exercise plans.
1.
2.
3.
4.
5.
 Nutrition Goals Exercise Goals

1. 1.

2. 2.

3. 3.

4. 4.

Next Nutrition Appointment

Date:

Time: