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Client Name (Initials)
Biochemical Data, Medical Tests and Procedures
125 ± 10%:
Adjusted Body Weight:
22 BMI category:
Physical Exam Findings/Clinical Observations
Food and Nutrition History
25 yrs Food Allergies:
Previous Medical History (PMH)/Medications/Supplements
Echinacea purpurea 500 mg 2x/d (OTC)
Vitamin C tablets 500 mg 1x/d (OTC)
lacto-ovo vegetarian for 1
lives alone & cooks most
exercises via walking 3 x/wk
for about 20 min/day
related to frequent consumption of high-fat cheeses & dairy
related to frequent consumption of high calorie items such as cheese & starches
caloric intake of 522 kcal more than estimated needs & 102%UBW
related to food & nutrition knowledge deficit
consumption of Echinacea purpurea & Vitamin C supplements w/ Clarinex
33 kcal/kg based on ______ kg actual/adjusted/ideal weight
0.8 g/kg based on ______ kg actual/adjusted/ideal wt or % total
To follow Therapeutic Lifestyle Changes (TLC) diet (25%-35% of total calories from fat & no more than 7% from saturated fat & less than 200 mg of dietary cholesterol per day. At least 3 servings of mono fats.)
Intervention # 1
To achieve goal of 25%-35% of total calories from fat & no more than 7% from saturated fat & less than 200 mg of dietary cholesterol per day. At least 3 servings of mono fats.
Intervention # 2
To achieve adequate caloric intake of 2000 kcal/d to maintain usual weight
Adapted from Supp Line 2007;29(6):12-23.
Intervention # 3
Monitoring and Evaluation
Indicator: What will be measured? How often?
Criteria: What is the standard or goal that
the indicator will be compared against?
For example: energy intake; 3 times/week
For example: amount of calories needed
re-assess fat & mono fat intake in 1 month #1
consume at least 3 foods rich in mono fats; aim for 25% calories from total fat (w/ no more than 7% from saturated fats); no more than 200 mg dietary cholesterol
re-assess caloric intake & weight in 1 month#2
consume about 2000 kcal/day; aim for 130 lbs
no Echinacea purpurea nor Vitamin C supplements
Excessive energy intakeExcessive oral food/beverage intakeInadequate fluid intakeExcessive fluid intakeExcessive bioactive substance intakeIncreased nutrient needsExcessive fat intakeInappropriate intake of fats (specify)Excessive protein intakeExcessive carbohydrate intakeInappropriate intake of types of carbohydrate (specify)Inadequate fiber intakeInadequate vitamin intake (specify)Inadequate mineral intake (specify)Swallowing difficultyAltered nutrition-related laboratory values (specify)Food-medication interactionOverweight/obesityFood-and nutrition-related knowledge deficitNot ready for diet/lifestyle changeDisordered eating patternUndesirable food choicesPhysical inactivityMalnutrition
Modify distribution, type, or amount of food and nutrients within meals or at specified timeMedical food supplements type: commercial beverageVitamin and Mineral SupplementsBioactive Substance SupplementNutrition-Related Medication ManagementInitial/brief nutrition educationComprehensive nutrition educationTheoretical basis/approach: Cognitive-behavioral therapyTheoretical basis/approach: Health Belief ModelTheoretical basis/approach: Transtheoretical model/stages of changeStrategies: Motivational InterviewingStrategies:Goal settingStrategies:Self-monitoringCoordination of other care during nutrition care: team meeting
PIONEER VALLEY REGIONAL SCHOOL DISTRICT NORTHFIELD, BERNARDSTON, LEYDEN, WARWICK SCHOOL HEALTH SERVICES INTERVAL HEALTH HISTORY 2010-2011 NAME: _______________________________________________ GRADE: _______ Dear Parent/Guardian: In order to keep your child’s health record up to date and to provide better health services to your child, we ask that you complete the following qu
RÉSUMÉ DES CARACTÉRISTIQUES DU PRODUIT DÉNOMINATION DU MÉDICAMENT Chlorure de méthylthioninium Proveblue 5 mg/ml solution injectable 2. COMPOSITION QUALITATIVE ET QUANTITATIVE Chaque ml de solution contient 5 mg de chlorure de méthylthioninium. Chaque ampoule de 10 ml contient 50 mg de chlorure de méthylthioninium. Pour la liste complète des excipients, voir rubrique 6.