Detailed Dietician Initial Assessment

Weight History • Dieting History: Client has tried various diets including keto, intermittent fasting, and calorie counting with limited success. • Weight Cycling: Client reports significant weight fluctuations, gaining and losing 20-30 pounds multiple times over the past five years. • Pre-morbid Weight: Client's stable weight before significant changes was around 150 pounds. 2. Body Image • Body Checking Behaviors: Client frequently checks their weight on the scale and measures their waist circumference daily. • Body Avoiding Activities: Client avoids swimming and wearing tight clothing due to body image concerns. 3. Disordered Eating/Eating Disorder Behavior • Restricting Intake: Client restricts food intake to less than 1200 calories per day, especially during weekdays. • Binge Eating: Client experiences binge eating episodes approximately twice a week, usually in the evening. • Overeating: Client reports occasional overeating during social events. • Self-induced Vomiting: Client denies any self-induced vomiting. • Exercise: Client exercises compulsively, running 5 miles daily regardless of weather or physical condition. • Rumination: Client denies any instances of food regurgitation or rumination. • Chewing and Spitting: Client denies chewing and spitting out food. • Laxative/Diuretic Use: Client occasionally uses laxatives, approximately once a month. • Diet Pills: Client has used diet pills in the past but not currently. • Night Eating: Client reports waking up at night to eat at least once a week. 4. Eating Behavior • Hunger/Fullness Cues: Client struggles to recognize hunger and fullness cues, often eating out of habit or stress. • Food Rules/Fear Foods: Client avoids carbohydrates and fears gaining weight from eating them. • Allergies/Intolerances: Client is lactose intolerant. • Vegan/Vegetarian: Client follows a vegetarian diet. 5. Nutrition Intake • Wakes Up: Client usually wakes up at 6:30 AM and drinks a glass of water. • Breakfast: Client eats oatmeal with fruit for breakfast around 7:00 AM. • Snack: Client has a mid-morning snack of a banana around 10:00 AM. • Lunch: Client eats a salad with tofu and various vegetables around 12:30 PM. • Snack: Client has an afternoon snack of nuts around 3:00 PM. • Dinner: Client eats a balanced meal with protein, vegetables, and grains around 7:00 PM. • Snack: Client has a small evening snack of yogurt around 9:00 PM. • Meals per Day: Client consumes three main meals and three snacks per day. • Fluid Intake: Client drinks approximately 2 liters of water daily. 6. Physical Activity Behavior • Current Activity: Client engages in running, yoga, and strength training, exercising 6 days a week. • Relationship with Physical Activity: Client has a love-hate relationship with exercise, feeling compelled to work out to manage weight. 7. Medical & Psychiatric History Client has a history of anxiety and depression, currently managed with therapy and medication. 8. Menstrual History • Age of Menses: Client began menstruating at age 13. • Dates of Last Period: Last menstrual period was on September 15, 2023. • Usual Cycle Length: Typical cycle length is 28 days. • Regularity of Cycle: Client reports regular menstrual cycles. • Symptoms: Client experiences mild cramps and mood swings. • Use of Contraception: Client uses oral contraceptive pills (OCP). 9. Gut/Bowel Health Client reports regular bowel movements with occasional constipation. 10. Pathology/Scans • ECG/BMD: Client had an ECG and bone mineral density scan last year, both results were normal. 11. Medications/Supplements Client is currently taking fluoxetine for depression and a multivitamin supplement. 12. Social History/Lifestyle • Living Status: Client lives with a roommate in an apartment. • Occupation: Client works as a graphic designer. • Alcohol Intake: Client drinks alcohol socially, about 2-3 times a month. • Smoking Status: Client does not smoke. • Stress: Client reports moderate stress levels due to work deadlines. • Sleep: Client sleeps approximately 7 hours per night but often feels tired. • Relaxation/Self-care Activities: Client practices meditation and enjoys reading for relaxation. • Other Allied Health Professionals: Client is also seeing a therapist for mental health support.