Standardized Dietitian Consult Report

Patient Name: PATIENT_NAME
Date of Visit: SESSION_DATE

Chief Complaint (CC): Fatigue, difficulty concentrating, weight gain, concern about dietary intake.

Dietary History:
• Typical Diet:
• Breakfast: Cereal
• Lunch: Sandwich
• Dinner: Pasta or pizza
• Snacks: Not specified
• Fruit and Vegetable Intake: Attempts to eat at least one serving of each per day, but unsure if adequate.
• Processed Food Intake: Admits to frequent consumption of processed foods like pizza and chips.
• Water Intake: Inadequate; primarily drinks coffee in the morning and one glass of water with lunch.
• Lactose Intolerance: Reports mild lactose intolerance.

Medical History:
• Hypothyroidism: Diagnosed, managed with Synthroid medication.

Medications:
• Synthroid: For hypothyroidism.
• Multivitamin:

Allergies:
• None: Reports no food allergies.

Social History:
• Exercise: Engages in walking a few times per week, but not into organized sports.
• Smoking: Non-smoker.

Family History:
• Mother: Type 2 diabetes.
• Father: High blood pressure.

Review of Systems (ROS):
• Constitutional: Fatigue, weight gain.
• Gastrointestinal: Decreased appetite, particularly in the mornings.
• Sleep: Difficulty falling asleep.

Nutritional Assessment:
• BMI: [Insert BMI] (calculated based on weight and height provided).
• BMI Category: [Insert BMI category] (e.g., overweight, obese).

Body Composition Analysis: Not performed during this visit.

Dietary Intake Analysis: To be completed based on a food diary for the next few days.

Nutritional Requirements: Not specified in the provided transcript.

Nutrition Diagnosis:
• Inadequate Fruit and Vegetable Intake: Based on patient report of consuming at least one serving per day, but unsure if adequate.
• Excessive Processed Food Intake: Patient admits to frequent consumption of processed foods.
• Inadequate Water Intake: Patient reports drinking primarily coffee and one glass of water per day.
• Possible Nutrient Deficiencies: Potential for deficiencies due to inadequate intake of fruits, vegetables, and water.

Diet and Meal Planning:
• Recommendations: Focus on increasing fruit and vegetable intake, reducing processed food consumption, and increasing water intake.

Nutritional Counseling:
• Recommendations: Provide guidance on meal planning, portion control, and healthy food choices.

Nutritional Education:
• Topics: Importance of balanced diet, hydration, and the role of fruits, vegetables, and whole grains in a healthy diet.

Specialized Diet Recommendations:
• Lactose Intolerance: Provide guidance on lactose-free alternatives and strategies for managing lactose intolerance.

Weight Management Strategies:
• Recommendations: Encourage regular physical activity, at least 30 minutes of moderate-intensity exercise most days of the week.

Prognosis: Good with adherence to recommended dietary and lifestyle changes.

Follow-up Plan:
• Schedule: Follow-up appointment in a few weeks to discuss progress and address any concerns.

Patient Education:
• Topics: Importance of a healthy diet, hydration, and regular physical activity for overall health and well-being.

Consultation Recommendations:
• Food Diary Review: Review food diary upon completion to assess dietary intake and provide further personalized recommendations.

Referral Recommendations:
• None: No referrals indicated at this time.