EXAMPLE

Client/Patient History
1. Personal story

Name: XXXXXXX

CH-1.1.1 Age 26
CH-1.1.2 Sex male
CH-1.1.4 Language Spanish
CH-1.1.5 Literacy Knows how to read and write
CH-1.1.6 Education Degree
CH-1.1.7 Role in the family Son

1.1 personal information

2. client/patient/family/health history

2.1 Nutrition-related medical/health history of the patient/client

or family

CH-2.1.1 Reason for consultation Concern about intake

CH-2.1.2 cardiovascular Hypertension (grandfather)
CH-2.1.3 endocrine/metabolic Diabetes (father)

3. Social history

3.1 social history

CH-3.1.2 Type of housing Own

CH-3.1.3 Domestic situation It has all the services
CH-3.1.5 Address Panuco River 1126
CH-3.1.6 Occupation Student
CH-3.1.7 Religion Catholic
CH-3.1.9 Daily stress level moderate

Food/Nutrition Related History (FH)

1 food and nutrient intake

 1.1.3 Food/meal environment

FH-[Link] Location Dining / work

FH-[Link] caregivers/companions They eat together

1.2 energy intake

FH-[Link] Total energy intake 3071 kcal

1.3 food and drink intake

1.3.1 ingestion of liquids / drinks

FH-[Link] amount of oral fluids 2 liters of water

1.3.2 food intake

FH-[Link] quantity of food (portions)

3.3 servings of vegetables, 0.8 servings

of fruit, 12 servings of fat-free cereals and
tubers, 0.5 servings of fat-free cereals
and tubers, 2.5 servings of low-fat animal
foods, 2.5 servings of semi-skimmed milk,
2.5 servings of milk with sugar, 3 servings
of oils and fats without protein, 1 serving
of sugars with fat.
FH-[Link] Types of food/meals
(characteristics and preferences) Fat-free vegetables, cereals and tubers,
low-fat foods of animal origin.
FH- [Link] meal/snack pattern 11:00 am breakfast, 03:00 pm snack 6:00
pm lunch 10:00 pm snack 23:00 pm
dinner

FH- [Link] food variety (FCC) Highly varied

 1.6 Macronutrient intake

1.6.1 Fat and cholesterol intake

FH-[Link] Total fats 124.5 gr representing 36.4% of the total
macronutrient intake
FH-[Link] dietary cholesterol
3.579 gr which represents 6.8% of fats

1.6.2 Protein intake

FH-[Link] Total protein 154.6 gr representing 20.13% of the total
macronutrient intake

1.6.3 Carbohydrate intake

FH-[Link] Total carbohydrates 327.7gr representing 42.6% of the total
macronutrient intake
FH-[Link] Sugar 21.8 gr representing .7 of the total
macronutrient intake

1.6.4 Fiber intake

Total fiber 13.24 gr

1.7 . Micronutrient intake

1.7.1 Vitamin intake

Vitamin A 722.21 micrograms
Folic Acid 79.15 mg

1.7.2 Ingestion of inorganic micronutrients and trace elements

Sodium 2877.57 mg
Calcium 2246.85 mg
Iron 13.3 mg

1.8 Knowledge/beliefs/attitudes
 3.1 Knowledge of food and nutrition
FH-3.2.7 readiness to change nutrition- Stage of change action
related behaviors

3.2 Beliefs and attitudes

4 Behavior

4.2 Avoided behaviors

FH-4.2.1 Avoid Added sugars
FH-4.2.2 Restrictive feeding Cooked Celery
FH-4.2.3 Avoided behavior Food preferences

4.4 Behavior during meal times

FH-4.4.1 Duration of meals 20 min

5. Factors affecting access to food/food-related

supplies

5.2 Availability of safe food and meals

FH-5.2.1 Availability of facilities to Shops, Market and Supermarket
purchase food
FH-5.2.3 Facilities for proper food Yeah
preparation
Yeah
FH-5.2.4 Availability for safe food storage

Biochemical data, medical tests and procedures (BD)

1.2 Electrolyte and renal profile

BD-1.2.2 creatinine 1.0mg/dl

1.5 Endocrine/glucose profile

BD-1.5.1 Fasting glucose 90 mg/dl
 1.7 Lipid profile
BD-1.7.1 Serum cholesterol 190 mg/dl
BD-1.7.7 Serum triglycerides 180 mg/dl

1.8 energy expenditure profile

BD-1.8.1 basal metabolic rate 1536 kcal

1.12 Urinary profile

BD-1.12.1 Urine color Yellow/Transparent
1.020
BD-1.12.3 Specific gravity of urine
BD-1.12.5 urinary volume 86 ml

ANTHROPOMETRIC MEASUREMENTS (AD)

1.1 BODY COMPOSITION/GROWTH/WEIGHT HISTORY

AD-1.1.1 Height/size 1.71 mts
AD-1.1.2 Weight 63.5 Kg
AD-1.1.3 Complexion Median
AD-1.1.5 BMI 21.58
AD-1.1.7 Estimation of body Visceral 24%, Bone 17.32%, Muscle
compartments 47.38%, Fat 11.2% and Total body water
60%

1 Nutrition-focused physical findings (PD)

1.1 Physical findings focused on nutrition

PD-1.1.1 General appearance Healthy appearance
PD-1.1.2 Body language confident
PD-1.1.6 Head and eyes Brilliant
PD-1.1.8 Skin Lightly moisturized

Comparison Standards (CS)

1 Energy requirements

1.1 Estimated energy requirements

 CS-1.1.1 Estimated total energy 1966.24 kcal ETA (8%) and GAF (20%)
requirements
CS-1.1.2 Method for estimating Fleish Formula
requirements

2 Macronutrient requirements
2.1 Estimated fat requirements

CS-2.1.1 Estimated total fat 30% of intake

requirements
CS-2.1.2 Type of grease required
Saturated less than 10% of total fats
CS-2.1.3 Method for estimating Recommended intake according to Gil
requirements A. nutrition treaty, 2005

2.2 Estimated protein requirements

CS-2.2.1 Estimated total protein 10-35% of intake
requirements
CS-2.2.3 Method for estimating Recommended intake according to Gil A.
requirements nutrition treaty, 2005

2.3 Estimated carbohydrate requirements

CS-2.3.1 Estimated total carbohydrate 40-65% of intake
requirements

CS-2.3.2 Type of carbohydrate required Simple carbohydrates < 10% of intake

CS-2.2.3 Method for estimating Recommended intake according to Gil A.
requirements nutrition treaty, 2005

2.4 Estimated fiber requirements

CS-2.4.1 Total estimated fiber 25-30 gr/day
requirements
CS-2.4.3 Methods for estimating Recommended intake according to Gil
requirements A. nutrition treaty, 2005

3 Liquid requirements
3.1 Liquid requirements

CS-3.1.1 Estimated total requirement 2.5 to 3 liters per day

 of liquids
CS-3.1.2 method for estimating Recommended intake according to Gil A.
requirements nutrition treaty, 2005
(20)
Nutritional diagnosis
DOMAIN No. PROBLEM ETIOLOGY SIGNS AND
SYMPTOMS
NEITHER- 5.10.2 NB-1.7 undesirable
food choices RDI > 2400mg/day,
Excessive mineral R24 and daily
intake (SODIUM) consumption
NEITHER- 5.10.2 NB-1.7 undesirable RDI 900mg/day,
food choices R24 and daily
Excessive mineral consumption
intake (CALCIUM)
NEITHER 5.8.5 NI-5.8.5 Insufficient NB-1.7 undesirable
fiber intake food choices Poor fiber intake,
RDI of 30gr/day,
R24 and
consumption diary
NEITHER 1.5 NI-1.5 excessive NB-1.7 undesirable
energy consumption food choices Excess of energy
requirement of
36%, Fleish
formula.
NEITHER 5.6.2 NI-5.6.2 Excessive NB-1.7 undesirable High triglyceride
fat intake food choices levels on clinical
examination

Nutritional diagnosis
Excessive sodium intake, excessive calcium intake, excessive energy intake,
insufficient fiber intake, related to undesirable food choices, evidenced by RDI, R24;
consumption diary, fleish formula. (18)

Nutritional intervention
Date No. From Frequency Duration cost
10/June/13 session
1 15 days 1hr 300
24/June/13 2 15 days 1hr 250
8/July/13 3 15 days 1hr 200
 FOOD/NUTRIMENT INDICATION (ND)

FOOD/NUTRIMENT INDICATION (ND)

1. Meals and
snacks:

ND-1.1 Diet Meal times and schedules:

general/correct Breakfast: 8 am
Lunch: 2 pm
Dinner: 8 pm
Snack (1): 11 am
Snack (2): 5 pm

Kilocalories: 2000

Nutrient distribution:
HC: 60%
Pt: 15%
Lip: 25%

[Link]
 ND-3.2.1 1 Berocca effervescent tablet (B complex), every 24 hours,
Multivitamin/mineral with food.

Brief and initial nutrition education (E)

E-1.1 Purpose of nutrition education: to reduce excessive cholesterol intake

E-1.2 Priority changes: consumption of foods high in cholesterol

Date Issue Activity to Duration assessment
E-1.3 essential be
information developed
Correct diet 10/ June Macronutrient Educational 45min Theoretical
balance game: plate questionnaire
of good
eating and
jug of good
drinking

NUTRITION EDUCATION (E)

2. Comprehensive nutrition education
E-2.1 Purpose of nutrition education: micronutrient balance
E-2.2 Recommended modifications: excessive sodium and calcium consumption and fiber
deficiencies
E-2.3 Date Issue Activity to Results Skill development
Advanced or be
related topics developed

Correct 10/ June types of dietary List different That the patient
diet/micronutrie fiber and foods types of knows the types
nts rich in it. foods of fiber and has a
according to criterion to select
the amount the most
and type of appropriate ones
fiber they for their needs
provide
 Sodium/ 24/ July Nutrition labels The patient will
calcium and contents per be able to review
content of serving the total
foods nutritional content
Review of based on the
labels of labeling of the
products that products they
are preferably consume.
consumed by
the patient

GUIDANCE AND INTERVENTION IN NUTRITION (C)

[Link] on Patient 2 Goal Estimated Evaluation %
theoretical situation Strategies date progress
knowledge

C-1.5 Action: The C-2.2 Goal Regulate 15 days Review the

Transtheoretical subject is setting: your R24 and
model/et apas of working on Instruct the sodium compare the
change the patient to and values
modifications record the calcium obtained with
that affect his sodium/calcium intake the initial ones
health, or on content on
the identified labels of
health commercial
problem. products he or
she consumes
so as not to
exceed the
amount.

(20)

Literature
Gil, A. (2005). Human Nutrition in the State of Health. Madrid: Panamericana.
Suverza, A. (2010). The ABCD of nutritional status assessment. Mexico: [Link].