By Lani | Initial Nutrition Consultation Notes

<u>Overview</u> - Client Name: [client's full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Age: [client's age] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Height: [client's height] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Occupation: [client's occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- **PRIMARY COMPLAINT – **[state the main reason client has come to see me today] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • Location: [where is the primary complaint located] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - **Onset: **[where/when did the primary complaint start or begin] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - **Provocation: **[what makes the primary complaint worse] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Palliation: **[what makes the primary complaint better] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Quality: **[how does the primary complaint present, e.g. stabbing pain in the left rib] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Severity: **[how severe is the primary complaint on a scale of 1-10] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Timing: **[is there a particular time that the primary complaint is worse or most prevalent] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Understanding: **[why/how does the client think the primary complaint began] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• History: **[what is the history of the complaint e.g. what treatment has the client already received, are there any notable events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- **ADDITIONAL COMPLAINTS – **[state any additional reason the client has come to see me today] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • Location: [where is the additional complaint located] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - **Onset: **[where/when did the additional complaint start or begin] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - **Provocation: **[what makes the additional complaint worse] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Palliation: **[what makes the additional complaint better] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Quality: **[how does the additional complaint present, e.g. stabbing pain in the left rib] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Severity: **[how severe is the additional complaint on a scale of 1-10] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Timing: **[is there a particular time that the additional complaint is worse or most prevalent] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Understanding: **[why/how does the client think the additional complaint began] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• History: **[what is the history of the complaint e.g. what treatment has the client already received, are there any notable events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- **REVIEW OF SYSTEMS – **(overview of the client's body systems) **• GIT: **[mention all information about the client's gastrointestinal system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Reproductive / Menstrual Cycle: **[mention all information about the client's reproductive system, including their menstrual cycle if they're female] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Nervous System: **[mention all information about the client's nervous system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Immune System: **[mention all information about the client's immune system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Cardiovascular System: **[mention all information about the client's cardiovascular system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Musculoskeletal: **[mention all information about the client's musculoskeletal system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Urogential: **[mention all information about the client's urogenital system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Integumentary System: **[mention all information about the client's integumentary system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Liver: **[mention all information about the client's liver] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- **LIFESTYLE – **(overview of the client's lifestyle) • Sleep: [explain the client's sleep quality, duration, timing, challenges, routines and any other relevant information provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Energy: **[explain the client's energy across the day, rate their energy on a scale of 1-10 with 10 being extremely energised] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - **Stress: **[explain the client's stress across the day, how does this stress present, what makes it worse or better, rate their stress on a scale of 1-10 with 10 being extremely] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Mood: **[explain the client's mood across the day, what makes it worse or better, rate their mood on a scale of 1-10 with 10 being happy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Physical Activity: **[explain the client's physical activity across the week, do they have an exercise regime, what are the physical requirements of their work, what kind of incidental activity do they do] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Other Social & Lifestyle Factors: **[explain the client's social and lifestyle factors, what are their social commitments, what are their lifestyle habits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- **PERSONAL HISTORY – **(overview of the client's personal history) **• Family Medical History: **[state the medical history on both the client's parent's sides, the medical history of their siblings and/or other family members] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Personal Medical History: **(provide an overview of the clients medical history) 0-4 years (early childhood) – [any relevant information about the client's medical history from the age of 0-4 years old] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 5-12 years (primary school) – [any relevant information about the client's medical history from the age of 5-12 years old] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 13-18 (high school) – [any relevant information about the client's medical history from the age of 13-18 years old] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 19-25 (young adult) – [any relevant information about the client's medical history from the age of 19-25 years old] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 26+ (adult years) – [any relevant information about the client's medical history from the age of 26 years old and above] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Last Medical Check-up: **[when was the client's last medical check up, what was the check up for, what were the outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- **DIETARY ANALYSIS OF A NORMAL DAY **(provide an overview of the client's diet on a normal week for them) • <u>Breakfast</u> – [does the client have breakfast, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• <u>Snack</u> **– [does the client have a mid morning snack, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • <u>Lunch</u> – [does the client have lunch, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - <u>Snack</u> – [does the client have an afternoon snack, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • <u>Dinner</u> – [does the client have dinner, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• <u>Dessert</u> **– [does the client have dessert, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • <u>Water</u> – [how much water does the client consume across the day, what are their water habits like, do they struggle with water intake] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• <u>Alcohol</u> **– [how many standard alcoholic drinks does the client have a week, what alcoholic drinks do they have, what is their relationship like with alcohol] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • <u>Other Beverages</u> – [each day other than water and alcohol what other beverages does the client have, what time do they have these, what quantities do they have] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • <u>Takeaway</u> – [across the week how many takeaway meals does the client have, what meals they have, why do they have these takeaway meals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **DIETARY ANALYSIS OF A BUSY DAY **(provide an overview of the client's diet on a busy week for them, how do their eating habits differ to a normal week) • <u>Breakfast</u> – [on busy days does the client have breakfast, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• <u>Snack</u> **– [on busy days does the client have a mid morning snack, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • <u>Lunch</u> – [on busy days does the client have lunch, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - <u>Snack</u> – [on busy days does the client have an afternoon snack, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • <u>Dinner</u> – [on busy days does the client have dinner, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• <u>Dessert</u> **– [on busy days does the client have dessert, if yes what time does the client have this, what do they eat, include quantity and brands where possible] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • <u>Water</u> – [on busy days how much water does the client consume across the day, what are their water habits like, do they struggle with water intake] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• <u>Alcohol</u> **– [on busy days how many standard alcoholic drinks does the client have a week, what alcoholic drinks do they have, what is their relationship like with alcohol] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • <u>Other Beverages</u> – [on busy days, other than water and alcohol what other beverages does the client have, what time do they have these, what quantities do they have] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • <u>Takeaway</u> – [on busy days / weeks how many takeaway meals does the client have, what meals they have, why do they have these takeaway meals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- ADDITIONAL DIETARY INFORMATION **• Cravings: **[does the client have any specific cravings, such as salty or sweet foods, specific brands, specific times of day] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Food Aversions: **[does the client have any foods they do not like or actively avoid] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • Allergies / Intolerances: [is the client allergic or intolerant to any foods] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - **Veggie Intake: **[how many cups of vegetables does the client typically have a day, what are their main vegetable sources they consume] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - **Fruit Intake: **[how many serves of fruit does the client typically have a day, what are their main fruit sources they consume] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- PHYSICAL ASSESSMENT **• Tongue: **(include details about the physical assessment of their tongue if a tongue analysis is complete, if not leave this empty) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Nails: **(include details about the physical assessment of their nails if a nail analysis is complete, if not leave this empty) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Capillary Return: **(include details about their capillary return if a capillary return test is complete, if not leave this empty) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Skin Turgor: **(include details about their skin turgor if this is discussed, if not leave this empty) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Eyes/undereyes: **(include details about their eyes and undereyes if these are discusses, if not leave this empty) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- CURRENT MEDICATIONS & SUPPLEMENTS **• Medications: **[list any medications the client is on (if any) and what are the dosages, when do they take the medication, how long have they taken this for] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **• Supplements: **[list any supplements the client is on (if any) and what are the dosages, when do they take the supplement, how long have they take this for] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)