Dietary Assessment Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Nutrition Note

Patient Identification: [Patient name, age, gender, relevant medical history, reason for nutrition consult]

History of Present Illness:
[Description of current nutrition-related concerns, symptoms, or reason for referral. Include relevant medical diagnoses, recent changes in health status, and chronological history of presenting issue.]

Dietary History:
(hyphenated list)
- [Usual meal pattern: number of meals/snacks per day, timing]
- [Food preferences, aversions, cultural or religious dietary practices]
- [Recent changes in appetite, intake, or weight]
- [24-hour dietary recall or typical daily intake]
- [Use of supplements or meal replacements]

Past Medical History:
(hyphenated list)
- [Relevant chronic conditions, surgeries, hospitalizations]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Include over-the-counter and supplements]

Allergies:
(hyphenated list)
- [Food allergies/intolerances]
- [Drug allergies]

Family History:
(hyphenated list)
- [Relevant family history of nutrition-related conditions]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]
- [Physical activity level: type, frequency, duration]

Anthropometric Data:
(hyphenated list)
- [Height (cm or in)]
- [Weight (kg or lb)]
- [BMI (kg/m2)]
- [Recent weight changes: amount, time frame]
- [Other relevant measurements: waist circumference, skinfolds, etc.]

Biochemical Data:
(hyphenated list)
- [Relevant lab results: glucose, lipids, electrolytes, renal function, etc.]

Physical Examination:
(hyphenated list)
- [General appearance]
- [Signs of nutrient deficiencies or excess]
- [Other relevant findings]

Nutrition Assessment:
[Summary of nutrition-related problems, contributing factors, and clinical interpretation. Include assessment of nutritional status, risk factors, and impact on health.]

Nutrition Diagnosis:
[Specific nutrition problem(s) identified, using standardized terminology if applicable.]

Nutrition Intervention/Plan:
(hyphenated list)
- [Goals of nutrition therapy]
- [Dietary recommendations]
- [Education provided]
- [Supplementation or enteral/parenteral nutrition if indicated]
- [Referrals to other providers]
- [Follow up plan]
- [Return precautions or instructions for patient]