MEDICAL NUTRITION THERAPY CHART AUDIT
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MEDICAL NUTRITION THERAPY CHART AUDIT

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MEDICAL NUTRITION THERAPY ASSESSMENT and OUTCOMES: HYPERLIPIDEMIA Dear Patient: Please provide as much information as possible in the SHADED areas PATIENT NAME: M F DOB: AGE: PHYSICIAN: ADDRESS: TELEPHONE: ID NUMBER: PREVIOUS MNT (NO. HRS): __MEDICARE B __NON-MEDICARE stTODAY’S DATE: 1 Visit Assessment Values GOALS DATE:________ (3 - 12 Month Follow-Up MNT OUTCOMES) Usual Blood Glucose: Total cholesterol: LDL-cholesterol: HDL-cholesterol: Triglycerides: Waist circumference (inches around): Blood pressure: Ht: Wt: Recently gained lost _______pounds Medications: cholesterol blood pressure water pill aspirin blood thinner Plus other medications: Dietitian Use OUTCOMES Tobacco use: Type: Amount per day: or amount per week: Exercise: Did doctor OK exercise? yes no Do you exercise? yes no Type: Minutes per day: Number of times per week: Medical problems: Digestive and/or ...

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MEDICAL NUTRITION THERAPY ASSESSMENT and OUTCOMES:HYPERLIPIDEMIA Dear Patient:Please provide as much information as possible in the SHADED areas PATIENT NAME:MAGE: PHYSICIAN:F DOB: ADDRESS: TELEPHONE: ID NUMBER:PREVIOUS MNT (NO. HRS):__MEDICARE B__NONMEDICARE st TODAY’S DATE:1 VisitAssessment Values GOALSDATE:________ (3  12 Month FollowUpMNT OUTCOMES)Usual BloodGlucose:  Totalcholesterol:  LDLcholesterol:  HDLcholesterol:  Triglycerides: Waist circumference (inches around): Blood pressure: Ht: Wt:Recentlygainedlost pounds Medications:cholesterolblood pressurewater pill as irinblood thinnerPlus other medications:  DietitianUse OUTCOMES Tobacco use:T e: Amount per day: or amount per week: Exercise: Diddoctor OK exercise?yesno Do you exercise?yesno T e: Minutes erda : Number of times perweek: Medical roblems: Di estiveand/or eliminationroblems: S m tomsareh bloodressure ouof hih blood cholesterol or hi havin :  OVER
st TODAY’S DATE:1 VisitAssessment ValuesDietitian UseOUTCOMES NUTRITIONPrevious diets: Eatin times: Breakfast:Lunch: Dinner:  Snack:Snack: Snack:Usual food intake: Select one:none=0 low=1 moderate=2 hih=3 verhi h=4  Code:Starches:codeStarches: _____ Fruits:Fruits: _____ Vegetables:Vegetables: _____ Milk, ourt:_____Milk, yogurt: Protein, meat:Protein, meat:_____ Fats:Fats: _____ Su ar,sweets: Sugar,sweets: _____ Estimate ofour dailcalorieCalories:___________intake erda :  CHO:_____  PRO:_____  FAT:_____ Portioncontrol:poorfairgoodvery good Cookingfacilities are:poorfairgoodvery good Person responsible for food buying/cooking: Appetiteis usually:poorfairgoodvery good Number of meals eaten inrestaurants erweek: Usually is:fast foodnotfast food Alcoholintake: aboutdrinks erdaweekmonth Type: Takesupplementof:  YESNO Vitamin B6:Vitamin B12Folate/Folic AcidVitamin E:Other Antioxidants:FiberAbout how often:dail4  6 times/week2  3 times/week Other vitaminsu lement/ dietarherb use:  OVER
PATIENT NAME:ID NUMBER:Page 3 of 4st TODAY’S DATE:1 VisitAssessment ValuesDietitian UseOUTCOMES Select one:none=0 low=1 moderate=2 hih=3 verhi h=4 E s,whole milk, butter, fattmeats, bacon, oran meats:code (Dietary cholesterol intake) Salt, chis, ickles,canned foods, cold cuts, sausae: code (Salt and sodium intake) E s,whole milk, butter, fattmeats, bacon stick mararine: code (Saturated fat intake) Baker ,donuts, cookies,otato chis, crackers:code (Trans fatty acids intake) Fruits, veies, wholerain bread/cereals, bran, oatmeal:code (Soluble fiber intake) Fruits, veies, Take Control®and Benecol®mar arineand salad dressin :code (Plant sterol/stanol esters intake) Fish, flax seed, walnuts: code (Omega 3 fatty acids intake)PSYCHO–SOCIAL, ECONOMICNumber ofmedical visitsin lastear to: Primar care hsician: Cardioloist: Dentist: Dietitian: Other: Select one:none=0 low=1moderate=2 hih=3 verhi h=4Usualstresslevel: Stress reduction techniques used: FinancialconcernsLivinsituation:live with someonelive aloneSu ortor anizationsou turn to for hels stems(famil , friends,orsu ort): poorfairgoodvery good Hi hesteducationlevel:rade schoolschoolhi hcolle eadvanced degreestudent now  OVER
st TODAY’S DATE:1 VisitAssessment ValuesEmployment:FTPTretired T eof work: Work is:physically activenot active Ethnicthat effectour eatinand reliious ractices: Estimate ourknowled eh cholesterol andh blood fats, hiabout hi the diet for: oorfair oodver ood Pastsuccess rateatchan inour behaviors for the better:  oorfair oodver ood “Readiness”e ourbehaviors: ouhave nowto chan Select one:none=0 low=1 moderate=2 high=3very high=4 Thin slife nowin oure more difficultthat would make behavior chan (Exam les: lostm ob,livin situationhas ustchan ed): OTHER NOTESRD Signature:_____________________________________________________________________________Copyright 2003 by Mary Ann Hodorowicz Consulting, LLC(708) 3593864hodorowicz@comcast.net www.maryannhodorowicz.com