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Dietitian Template

Detailed Dietician Initial Assessment

A professional Dietitian template for healthcare professionals.
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About this template

This Initial Session template is designed for dietitians to comprehensively document a client's weight history, body image, eating behaviors, nutrition intake, physical activity, and medical history. It includes sections for disordered eating behaviors, menstrual history, gut health, and social lifestyle factors. This template helps dietitians gather detailed information during the first consultation to create a personalized nutrition and wellness plan. Ideal for dietitians, nutritionists, and other healthcare providers focusing on eating disorders and weight management, this template ensures a thorough assessment of the client's dietary and lifestyle habits.

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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.
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Specialty

Dietitian

Used

259 times

Type

Note

Last edited

9/6/2024

Created by

Fiona Kupresanin

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