Accurate and thorough clinical documentation is essential for dietitians to provide effective patient care. A well-structured initial assessment captures critical information that guides dietary planning and monitoring. Here's a detailed walkthrough on writing a dietitian initial assessment using the provided template.

1. Weight History

This section should outline the patient's past dieting efforts, weight fluctuations, and stable weight point. For example:

Dieting History: The client has attempted several diets such as keto, intermittent fasting, and calorie counting with minimal success.

Weight Cycling: Reports indicate significant weight fluctuations, with gains and losses of 20-30 pounds over the past five years.

Pre-morbid Weight: The stable weight before significant changes was approximately 150 pounds.

2. Body Image

Document the patient's behaviors and feelings about their body. Example:

Body Checking Behaviors: The client frequently checks their weight and measures waist circumference daily.

Body Avoiding Activities: The client avoids swimming and wearing tight clothing due to body image concerns.

3. Disordered Eating/Eating Disorder Behavior

This section explores various eating behaviors and patterns. For instance:

Restricting Intake: The client restricts food intake to less than 1200 calories per day, especially during weekdays.

Binge Eating: Experiences binge eating episodes twice a week, typically in the evening.

4. Eating Behavior

Assess the patient’s relationship with food and eating habits. Example:

Hunger/Fullness Cues: The client struggles to recognize hunger and fullness cues, often eating out of habit or stress.

Food Rules/Fear Foods: The client avoids carbohydrates due to fear of weight gain.

5. Nutrition Intake

Detail the patient's daily dietary intake to identify patterns and nutritional gaps. Example:

Breakfast: Oatmeal with fruit at 7:00 AM.

Lunch: Salad with tofu around 12:30 PM.

6. Physical Activity Behavior

Document the patient's exercise habits and attitudes. Example:

Current Activity: Engages in running, yoga, and strength training six days a week.

Relationship with Physical Activity: Feels compelled to work out to manage weight.

7. Medical & Psychiatric History

Capture relevant health history impacting dietary planning. Example:

The client has a history of anxiety and depression, managed with therapy and medication.

8. Menstrual History

Include relevant menstrual history if applicable. Example:

Regularity of Cycle: Reports regular menstrual cycles with mild cramps.

9. Gut/Bowel Health

Include information about digestive health. Example:

The client reports regular bowel movements with occasional constipation.

10. Pathology/Scans

Summarize any relevant medical tests and results. Example:

ECG/BMD: The client had normal results from an ECG and bone mineral density scan last year.

11. Medications/Supplements

List current medications and supplements. Example:

The client takes fluoxetine for depression and a multivitamin supplement.

12. Social History/Lifestyle

Understand the patient's lifestyle factors influencing health. Example:

Living Status: Lives with a roommate in an apartment.

Alcohol Intake: Social drinking 2-3 times a month.

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