Initial Dietetic Assessment

Initial Dietetic Assessment Date: [Date of assessment] Demographics: - Name: [Patient's full name] - DOB: [Patient's date of birth] - Age: [Patient's current age] - Gender: [Patient's gender] Referral Details: - Referred by: [Name and title of referring healthcare provider] - Reason for referral: [Primary reason for referral to dietitian] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical History: - Relevant medical conditions: [List of pertinent medical diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Medications: [Current medications, including dosages and frequencies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Allergies/intolerances: [Known food or medication allergies or intolerances] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Anthropometrics: - Height: [Patient's height in centimetres] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Weight: [Patient's current weight in kilograms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - BMI: [Calculated Body Mass Index] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Waist circumference: [Measurement of waist circumference in centimetres] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Biochemistry: - Recent pathology results: [Relevant blood test results, such as glucose, lipids, or micronutrient levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Nutrition-focused Physical Examination: - General appearance: [Overall physical appearance and body composition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Oral health: [Condition of teeth, gums, and any dental appliances] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Skin integrity: [Presence of wounds, rashes, or other skin conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Diet History: - Usual eating pattern: [Description of typical daily meals and snacks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Food preferences/aversions: [Favourite foods and any food dislikes or avoidances] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Appetite: [Subjective assessment of appetite, such as good, fair, or poor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Fluid intake: [Estimated daily fluid intake, including type and amount] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Nutrition-related Symptoms: - Gastrointestinal issues: [Presence of symptoms such as nausea, vomiting, diarrhoea, or constipation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Other relevant symptoms: [Additional symptoms that may impact nutrition, such as fatigue or taste changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Physical Activity: - Type and frequency: [Description of regular physical activities and exercise habits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Psychosocial Factors: - Living situation: [Current living arrangements, such as alone, with family, or in a care facility] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Support network: [Availability of family, friends, or caregivers to assist with nutrition-related tasks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Barriers to dietary changes: [Potential obstacles to implementing nutrition recommendations, such as financial constraints or limited cooking skills] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Nutrition Assessment: - Estimated energy requirements: [Calculated daily calorie needs based on age, sex, weight, height, and activity level] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Estimated protein requirements: [Calculated daily protein needs based on weight and medical condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Identified nutrition issues: [Summary of key nutrition problems or risk factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Nutrition Diagnosis: [Specific nutrition diagnosis using standardised terminology] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Nutrition Intervention: - Goals: [Short-term and long-term nutrition goals based on assessment findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Nutrition education provided: [Topics covered during nutrition counselling session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Strategies discussed: [Specific dietary modifications or behaviour changes recommended] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Nutrition Monitoring and Evaluation: - Parameters to monitor: [Key indicators to assess progress, such as weight, lab values, or dietary intake] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Follow-up plan: [Recommendations for future dietitian visits or coordination with other healthcare providers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Dietitian's full name and credentials] (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)