NUTRITION NOTE (Initial or follow-up)

Date of Visit:

Appointment Codes:

Time with patient:

In-person or virtual appointment:

NUTRITION ASSESSMENT:

MEDICAL CHART REVIEW:

Age:

Sex:

Past Medical History:

Anthropometrics:

Height:
Weight history (if appropriate):
BMI (if appropriate):
Usual Body Weight (UBW):
Ideal Body Weight (IBW):

Labs:

Medical tests (if appropriate):

Significant Nutrition Medications:

SOCIAL AND DIET HISTORY

Subjective reports provided by the patient:

Appetite:
Chew/Swallow:
Nausea or Vomiting:
Constipation or Diarrhea:
Other GI:
Known Food Allergies:

Diet Followed at Home:

Food Preferences:
 DIETARY INTAKE: meals/day and snacks/day.
B(AM):
L(PM):
D(PM):
SNACKS:
FLUIDS:
ETOH:

Physical activity history and limitations:

NUTRITION FOCUSED PHYSICAL EXAM (NFPE):

ESTIMATED NUTRITION REQUIREMENTS:

Calories:
Protein:
Carbohydrates:
Fluid:

NUTRITION DIAGNOSIS:
Problem:
Etiology:
Signs/Symptoms:

NUTRITION INTERVENTION (COUNSELING/EDUCATION):

Educational Materials Provided:

NUTRITION MONITORING AND EVALUATION:

GOALS (as verbalized by the patient):

Follow-up appointment date:

COORDINATION OF CARE:

Collaboration/referral to:
Recommend the following labs:
Recommend the following supplementation:
Monitor per team meeting.