Intern Referral Date: SOAP no:

PATIENT DATA

Name: Gender: Age: DOB:

Occupation: Marital Status: Ward: DOA:

MR No. Contact Details:

Medical Diagnosis:

1. 4.
2. 5.
3. 6.

Nutrition Diagnosis:
1. 4.
2. 5.
3. 6.

Relevant Medical history:

Relevant Drug history:

Social/ Family history:

 ANTHROPOMETRY

Height: Current Weight: Usual Weight:

IBW: %IBW: % Usual Weight:
BMI: % Weight Change: Duration (in how many weeks/months):

BIOCHEMICAL LABORATORY VALUES

Normal Values Normal Values

Date Test Name Result Date Test Name Result
with Units with Units

CLINICAL FINDINGS

Fluid Intake: IV: Urine Output:

Skin/ mucosal changes

Skin: Nails:
Mouth: Eyes:
Teeth/gums: Lips:
Tongue: Hair:

GI Functions

Appetite: Taste/ Smell:

Nausea: Acidity:
Vomiting: Indigestion:

Bowel Function: Bowel Frequency:

Other:

Functional Capacity: SGA Rating

 DIET HISTORY SHEET

Favorite foods and frequency of intake. (Daily, once/twice a week, once/twice a month)

Foods that you dislike:

Foods that you never eat:
Foods that you seldom eat:

How would you describe your appetite?

How often do you feel satisfied after eating meals?

How often do you eat between meals?

How often do you eat out the following in a week?
Snacks 7 6 5 4 3 2 1 0
Meals 7 6 5 4 3 2 1 0

How many times a week do you eat the following meals?

Breakfast 7 6 5 4 3 2 1 0
Lunch 7 6 5 4 3 2 1 0
Evening tea 7 6 5 4 3 2 1 0
Dinner 7 6 5 4 3 2 1 0

Do you have any food allergies or intolerances? If yes, Specify

Have you been on a special diet? If yes, Specify
Did you follow the diet?
Strictly Most of the time Occasionally Never

Are you taking any nutritional supplements? If yes, Specify

Are you taking any traditional remedies for your illness?

Are you taking any traditional remedies for digestion?

Do you eat anything which is usually not considered a food and how often?

Do you smoke How many a day?

FOOD FREQUENCY
How many times a week do you eat the following food?

Food - - - - - - - - -

Milk 7 6 5 4 3 2 1 0 7

Yogurt 7 6 5 4 3 2 1 0 7

Lassi 7 6 5 4 3 2 1 0 7

Eggs 7 6 5 4 3 2 1 0 7

Meat 7 6 5 4 3 2 1 0 7

Poultry 7 6 5 4 3 2 1 0 7

Fish 7 6 5 4 3 2 1 0 7

Fruits 7 6 5 4 3 2 1 0 7

Vegetables, leafy 7 6 5 4 3 2 1 0 7

Potatoes 7 6 5 4 3 2 1 0 7

Pulses 7 6 5 4 3 2 1 0 7

Wheat flour 7 6 5 4 3 2 1 0 7

Rice 7 6 5 4 3 2 1 0 7

Cake/pastries/biscuits 7 6 5 4 3 2 1 0 7

Milk based deserts 7 6 5 4 3 2 1 0 7

Carbonated drinks 7 6 5 4 3 2 1 0 7

Fruit juice 7 6 5 4 3 2 1 0 7

Tea/coffee 7 6 5 4 3 2 1 0 7

Mithai 7 6 5 4 3 2 1 0 7

Fried foods 7 6 5 4 3 2 1 0 7

Toffee/chocolate 7 6 5 4 3 2 1 0 7

Butter/cream/margarine 7 6 5 4 3 2 1 0 7
 24-Hr RECALL
Time Food or Quantity CHO Protein Fat Kcal Fluid
Beverage consumed g g g (oral/
consumed IV)
ml

Total Intake
 USUAL INTAKE

Meal
Food Item Amount Exchanges
Time

Breakfast
Time of day

Morning snack
Time of day

Lunch
Time of day

Afternoon tea
Time of day

Dinner
Time of day

Bedtime snack
Time of day
 Summary
Meal/ Snack / Time
Food Group Breakfast Snack Lunch Snack Dinner Snack Total CHO Protein Fats Calories
servings/ (g) (g) (g)
day
Starches
Fruit
Milk
Low, Reduced, Whole
Vegetables
Meat
Lean, Medium, High
Fats

CHO Choices Total

grams
Calories/ ×4= ×4= ×9= Total
gram Calories
Percent
calories

Nutrients Consumed RDA Int. Nutrients Consumed RDA Int

Total Kcal Thiamine
CHO Riboflavin
Protein Vitamin B12
Saturated Fat Iron
Poly unsaturated Fat Calcium
Cholesterol Sodium
Vitamin A Potassium
Vitamin C Phosphorous

Nutrient Intake Analysis:

•
•
•
•
•
•
 Drug and Nutrient Interaction

Drug Name Generic Name Mode of Action Side Effects Interaction with Nutrients
 MEDICAL NUTRITION THERAPY

Estimated Requirements

Kcal: Fat:

CHO: Fluids:

Protein: Micronutrients:

Feeding Route:

Diet Order:

Mechanism of Diet:

Suggested Supplements:
Suggested Physical activity:

Exchange Table
Food Group Total CHO Protein Fat Calories
servings/ g g g Kcal
day
Milk
low, reduced, whole
Fruit
Vegetables
Starches
Meat
lean, medium, high
Fat

Total Grams
Calories/g ×4 = ×4 = ×9 = Total
kcal
% Calories
 WORKSHEET A

Patient Name: Medical Diagnosis:

Nutritional Diagnosis:

S:

O:

A:

P:
 WORKSHEET B

Nutrition Management Plan

Patient Name: Medical Diagnosis:
Nutrition Diagnosis:

Date Nutritional Problem Intervention Expected Outcome

 WORKSHEET C

Nutrition Education Plan

Dietary Guidelines and Counselling

•
 Name of the intern:

Remarks and Signatures of Preceptor:

Remarks and Signatures of Advisor: