Nutritional Assessment Form- Orbera Patients Katie Leahy, MS RDN LD
|
|
- Allison Horn
- 5 years ago
- Views:
Transcription
1 Nutritional Assessment Form- Orbera Patients Katie Leahy, MS RDN LD First Name Last Name Please indicate your preferred method of contact: home cell text other: Sex: Male Female Birth date: / / Age: Height Current Weight Desired body weight Occupation Martial status Do you have children? Yes No Age of children Primary Care Physician: Personal History (check all at that apply): Arthritis Stroke High Cholesterol High Blood Pressure Diabetes Type 1 diabetes Type 2 diabetes Cancer What type? Surgeries What type? Thyroid Problems Hyperthyroid Hypothyroid Food Allergies To what? Depression Smoke Cigarettes Indicate daily stressors and rate the level of stress from 1 (low) to 10 (high): Work Family Social Finanical Health Other How many hours of sleep do you need to feel rested? How many hours do you get? To what extent will you commit to achieving better health? Little Moderate Major Extreme Is there anything additional about your health history that you feel is important to mention?
2 DIET HISTORY Are you currently taking any food or nutritional/herbal supplements? Yes No If yes, please indicate which ones: What meals do you eat regularly: Breakfast Lunch Dinner Snacks Who prepares the majority of your meals? Who shops for food? Food Dislikes Diet restrictions or limitations? (Health, cultural, religious, or other): Food Allergies or intolerances? Do you crave certain foods? Sweets Bread/Pasta Fried foods Alcoholic drinks Sodas Meat Other: Eating Style: Based on how you eat on a regular basis, please check all that apply Fast eater Erratic eater Emotional eater (stressed, bored, sad..) Late night eater Time constraints Dislike healthy food Travel frequently Do not plan meals/meus Rely on convenience items Family member(s) have different tastes Love to eat Eat too much Eat because I have to Negative relationship with food Confused about food/nutrition Fast food Graze/snack all day Poor snack choices The biggest challenge(s) to reaching my nutrition goals is/are: Do you want to change your eating habits? Yes No What are your expectations for the registered dietitian?
3 Beverage intake: Please indicate the beverages you drink, how often, and how much. Beverage Type Daily Amount Weekly Amount Example: Coffee: x Reg Decaf Latte 2-8oz cups Water: Coffee: Reg Decaf Latte Tea: Juice: Natural Fruit drinks Soda: regular diet Milk: Whole 2% 1% Skim Milk alternative type: Alcohol: Wine Beer Liquor Other:
4 Food Intake: Please indicate the frequency that you eat the following: How often do you eat: Fast Food Restaurant Food Vending Machine Food Cafeteria or Buffet Food Frozen Meals Home-Cooked Meals Leftovers Beef (Hamburger, steak, etc.) Pork (Chop, bacon, ham, etc.) Lamb Poultry (Chicken, turkey) Deli Meat, type: Fish, type: Soyfoods, type: Beans, type: Crackers, type: Cookies, cakes, muffins Whole grains, type: Fresh/raw/frozen/canned vegetables Fresh/frozen/canned fruit Margarine Dairy (milk, yogurt, cheese, butter) French Fries Fried Meat (chicken, fish) Artificial sweeteners, type: Meal Replacement, type: Other: Never month Once/ week week Once/ day day
5 Physical Activity Activity Type/Intensity (low-moderatehigh) # Days per week Duration (minutes) Stretching/Yoga Cardio (Walking, jogging, biking, etc.) Strength-Training (lifting weights) Sports or leisure Other (describe) Does anything limit you from being physically active? On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following: To improve your health, how willing are you to... Significantly modify your diet Keep a record of everything you eat daily Modify your lifestyle (ex. Sleep habits, physical activity) Engage in regular exercise/physical activity Follow up with the dietitian on a monthly basis via phone
Nutrition Assessment
Today s Date: Basic Information Name: Age: Gender: Date of Birth: Phone Number: Email Address: I prefer to be contacted via (please circle): phone email Reason for your visit: Occupation: Do you have children?
More informationReferred Patient Nutrition Assessment Form
One s health and well-being are influenced by many different things, including lifestyle, family history, emotional health, and nutrition/eating habits. Please complete the following questionnaire to the
More informationEmily Murray MS, RD, LDN Nutritionist / Registered Dietitian 110 West Lancaster Avenue Wayne PA (610)
Emily Murray MS, RD, LDN Nutritionist / Registered Dietitian 110 West Lancaster Avenue Wayne PA 19087 (610) 574 0079 emilymurray1@gmail.com Dietitian History Questionnaire and Assessment General Information:
More informationIntroduction to the Lifestyle Survey
Introduction to the Lifestyle Survey This program is designed to help lower your chances of getting heart disease. To get started, we need to know about your current eating and physical activity habits.
More informationLifestyle and Metabolic Medicine
Lifestyle and Metabolic Medicine Demographics First Name Date of Birth / / Mailing Address City, State, Zip code Preferred phone Secondary phone Email address Referred by Primary Care Physician New Patient
More informationBariatric Patient Nutrition & Lifestyle History. What Bariatric procedure are you considering? Bypass (RNY) Sleeve
Bariatric Patient Nutrition & Lifestyle History Name Patient ID # Date 5% goal weight What Bariatric procedure are you considering? Bypass (RNY) Sleeve Weight History Current weight: lbs. What has been
More informationNutrition Tips to Manage Your Diabetes
PATIENT EDUCATION patienteducation.osumc.edu As part of your diabetes treatment plan, it is important to eat healthy, stay active and maintain a healthy body weight. This can help keep your blood sugar
More informationNew Patient Nutrition Assessment Form
One s health and well-being are influenced by many different things, including lifestyle, family history, emotional health, and nutrition/eating habits. Please complete the following questionnaire to the
More informationLIFE STYLE ASSESSMENT FORM. Name: Date: Age: Sex:
LIFE STYLE ASSESSMENT FORM Name: Date: Age: Sex: Please answer each of the following questions. If you require additional space, there s a blank Page at the end of the form. What is your purpose in coming
More informationNutrition Initial Assessment
Nutrition Initial Assessment Client Name: Referring Physician: Home Phone: Home Address: Date: Email: What are the goals that you are trying to achieve with your initial appointment? Past Medical History:
More informationNUTRITION EDUCATION PACKET
NUTRITION EDUCATION PACKET Date: DIRECTIONS FOR SUBMITTING NUTRITION EDUCATION PACKET: 1. Complete the Client Information Page. 2. Complete the Nutrition and Physical Activity Assessments. 3. Complete
More informationNutrition First Because it matters.
LuAnne Petrie Nutrition Consultant MS, RD, CDE Nutrition First Because it matters. 415 State Route 34 Colts Neck NJ 07722 info@nutritionfirstllc.com www.nutritionfirstllc.com (908) 692-4140 BACKGROUND
More informationPhone (h) (w) (c) Address. Referred by. Birthday Age Height Weight. Ethnicity Marital Status Children. Occupation Hours in regular work week
Client Intake Form Please fill out the following questions as best you can. If there is a particular question you don t understand or want to fill out, we can discuss them at our first meeting. Thank you.
More informationNutritional Status Questionnaire Personal Assessment
Personal Assessment www.mariemurphyhealthfitness.com marie@mariemurphyhealthfitness.com Tel: 085 1965468 Marie Murphy 2012. All Rights Reserved. No part of this document or any of its contents may be reproduced,
More informationDIABETES SELF MANAGEMENT EDUCATION / NUTRITION COUNSELING INITIAL ASSESSMENT. NAME Today s Date
NAME Today s Date DATE OF BIRTH CONTACT INFORMATION: Home Number Cell phone number Work Number Okay to call at work? No Yes Answering machine No Yes Ok to leave message Your own personal Email Address
More informationLifestyle and Metabolic Medicine
Lifestyle and Metabolic Medicine New Patient Intake Form - fax completed form to 206.720.7448 or bring to your first appointment. Demographics First Name Date of Birth Mailing Address City, State, Zip
More informationAndrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ
Background Information Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ 08816. aberezrd@njpedsrd.com Adult Patient Nutrition Assessment/Diet History Form
More informationSUPPORT STAFF TRAINING TOOLS MAINTAINING HEALTH. THE HEALTHY MENU (Including the MyPlate Information)
SUPPORT STAFF TRAINING TOOLS MAINTAINING HEALTH THE HEALTHY MENU (Including the MyPlate Information) Training Program Specialists, LLC 9864 E. Grand River, Suite 110-320 Brighton, Michigan 48116 Phone:
More informationWEEK 1 GOAL SETTING & NUTRITION 101. with your Supermarket Registered Dietitian
WEEK 1 GOAL SETTING & NUTRITION 101 with your Supermarket Registered Dietitian Welcome to Week 1! We are excited you have decided to join us on this wellness journey! Please note that you should consult
More informationProtein Power For Healthy Eating
Protein Power For Healthy Eating What is Protein? Protein is: An essential nutrient. Used to build things in our bodies such as muscle. Made up of 20 amino acids, or building blocks. 9 of the 20 amino
More informationElite Health & Fitness Training, Inc. FOOD HISTORY QUESTIONNAIRE
FOOD HISTORY QUESTIONNAIRE Name: Date: Height: Weight: Age: Sex: Weight History: Have you ever tried to lose weight before or are you currently trying to lose weight? If yes, explain: Do you currently
More informationGo NAP SACC Self-Assessment Instrument
Go NAP SACC Self-Assessment Instrument Date: Program Name: Enrollment ID#: Child Nutrition Go NAP SACC is based on a set of best practices that stem from the latest research and guidelines in the field.
More informationStaying Healthy with Diabetes
Staying Healthy with Diabetes Note to the Health Care Provider: Topics in this handout are discussed in Chapters 6 and 13 of the American Dietetic Association Guide to Diabetes Medical Nutrition Therapy
More informationLipid Clinic Name DOB / / Primary Care MD Cardiologist Endocrinologist
Lipid Clinic Name DOB / / Date Primary Care MD Cardiologist Endocrinologist Allergies to medications (please include reaction) Marital Status (Please circle) Educational Level (Please circle highest level)
More informationA Healthy Lifestyle. Session 1. Introduction
A Healthy Lifestyle Session 1 Introduction Introduction A Healthy Eating Plan How Can Healthy Eating Improve Your Health? Healthy eating can improve your health in many ways. It helps to: Prevent many
More informationYOU ARE WHAT YOU EAT. 2. Do you eat more packaged (frozen or canned) fruits & vegetables than fresh?
YOU ARE WHAT YOU EAT 1. Do you shop for food less frequently than every four days? 2. Do you eat more packaged (frozen or canned) fruits & vegetables than fresh? 3. Do you eat more cooked vegetables than
More informationBeverage Guidelines: 1 up to 3 Years
Beverage Guidelines: nutritionally-equivalent nondairy beverages like soy, rice, or lactose-free milks with medical permission). nutritionally-equivalent nondairy beverages like soy, rice, or lactose-free
More informationThe Johns Hopkins Diabetes Center JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT. Name: Marital Status: M S W SEP D
JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT Date: JHH # I. General Information Name: Marital Status: M S W SEP D Address: Phone: Home: Work: Email: Fax: Sex: M F Date of
More informationeat well, live well: EATING WELL FOR YOUR HEALTH
eat well, live well: EATING WELL FOR YOUR HEALTH It may seem like information on diet changes daily, BUT THERE IS ACTUALLY A LOT WE KNOW ABOUT HOW TO EAT WELL. Eating well can help you improve your overall
More informationGo NAP SACC Self-Assessment Instrument for Family Child Care
Go NAP SACC Self-Assessment Instrument for Family Child Care Date: Your Name: Child Care Program Name: Child Nutrition Go NAP SACC is based on a set of best practices that stem from the latest research
More informationKidney Disease and Diabetes
Kidney Disease and Diabetes What is diabetes? Diabetes is a disease where your body cannot properly store and use food for energy. The energy that your body needs is called glucose (sugar). Glucose comes
More informationMaking Meals Matter. Tips to feed 6-12 year olds. Healthy eating for your school-age child
Making Meals Matter Tips to feed 6-12 year olds Healthy eating for your school-age child Your child learns healthy eating from you. Your elementary- school child needs you to guide them and to model healthy
More informationSynergy Integrative Medicine. Nutrition Intake Form. Date of Visit. Phone # (best) Explain. Occupation: Primary Care Provider:
Synergy Integrative Medicine Nutrition Intake Form Name Address Date of Visit City/State/Zip Phone # (best) Age Date of Birth Email Gender (circle): M / F Current height Current weight Goal weight Have
More informationFitness. Nutritional Support for your Training Program.
Fitness Nutritional Support for your Training Program www.inovacure.com Fitness You should not have to diet constantly to maintain your weight. In fact, the best way to maintain your weight over the long
More informationEXHIBIT C Center for Science in the Public Interest Publisher of Nutrition Action Healthletter www.cspinet.org/nutritionpolicy EXHIBIT C Committee Name OBESITY Document consists of 43 SLIDES. Entire document
More informationNutrition Consultation Questionnaire
Diana Dugan Richards RDN LDN 23 Main Street, Suite A, Watertown, MA 02472 dianaduganrichards@gmail.com (617) 678-0607 Nutrition Consultation Questionnaire Name Date of Visit How did you hear about Namaste
More informationPolicy. (name of organization or group) is concerned with the health of our (employees, members, etc.) Signature Title Date
Sample Healthy Meetings and Events Policy For use within organizations, agencies, and community groups where foods or beverages are served. Policy (name of organization or group) is concerned with the
More informationComfort Contract What is said in this room stays in this room. No computers or cell phones during class time. Speak from your own experience.
WHAM Handouts 1 Comfort Contract What is said in this room stays in this room. No computers or cell phones during class time. Speak from your own experience. Nothing about me without me! Go easy on aftershave
More informationHealth History. Date. Address. City State Zip. Age Height Weight BMI. Date of birth Male Female. . Are you currently a patient at OHSU?
OHSU BARIATRIC SERVICES Health History Please fill out this form completely and email or fax to the contact information at the bottom of this form. We will contact you to set up an appointment. Date Name
More informationCHEK NUTRITION AND LIFESTYLE QUESTIONNAIRES FOR HLC 1
Corrective Holistic Exercise Kinesiology CHEK Holistic Lifestyle Coach Level 1 CHEK NUTRITION AND LIFESTYLE QUESTIONNAIRES FOR HLC 1 You Are What You Eat 1. Do you shop less frequently than every four
More informationCurrent Health Profile Please total scores on all pages and write the total at the end before
Name Date: Current Health Profile We ask these questions in order to locate potential causes of your current health problems. We are not here to judge you. Your honest answers will give us the ability
More information3.2 For breakfast, our students usually have: sandwiches, baked eggs, omelet, cereal, fruit, salad, yoghurt, tea, coffee.
EATING HABITS FOR A HEALTHY LIFE WE ASKED THESE QUESTIONS BELOW What s the most important meal in a day in your daily life? What kind of food do you eat at breakfast? How often do you eat out? What kind
More informationWork-Time Snack Habits and Vending Machine Use Survey2
Work-Time Snack Habits and Vending Machine Use Survey2 SNACK HABITS: This section asks about the types of snacks you have at work. Please mark how often you have them. Salty Snacks: Popcorn, chips, chex
More informationStaying healthy while taking antipsychotic medications
Staying healthy while taking antipsychotic medications For patients and families You are taking antipsychotic medications to help your mental health. Like all medications, they can cause side effects.
More informationKnow Your Numbers Handouts
Calculating Your Body Mass Index (BMI) 1. Write down your weight in pounds (example: 190) 2. Multiply that number by 703 (190 x 703 = 133,570) 3. Multiply your height in inches by itself ( 70 x 70 = 4,900)
More informationDate of Interview/Examination/Bioassay (MM/DD/YYYY):
PhenX Measure: Dietary Intake (#231200) PhenX Protocol: Dietary Intake (#231201) Date of Interview/Examination/Bioassay (MM/DD/YYYY): SP = Survey Participant 1. These questions are about the different
More informationDrinks, Desserts, Snacks, Eating Out, and Salt
Snacks, Eating Out, Session 3 Assessment Background Information Tips Goals Assessment On an average DAY, Desirable Could be improved Needs to be improved 1a. How many 12-ounce servings of sugar-sweetened
More informationNutrition New Patient Intake Form
Nutrition New Patient Intake Form General Information Name Date: Preferred Date of Birth Gender: M F Height Weight Genetic Background African American Native American Hispanic Caucasian Asian Other (please
More informationFOOD IS FUEL EATING PLENTY OF HIGH QUALITY PERFORMANCE FOOD + SPORT SPECIFIC TRAINING + REST =WINNING ATHLETES
SPORTS NUTRITION IMPROVING PERFORMANCE THROUGH FOOD FOOD IS FUEL EATING PLENTY OF HIGH QUALITY PERFORMANCE FOOD + SPORT SPECIFIC TRAINING + REST =WINNING ATHLETES THE BASICS Make food work for you! EAT
More informationMedication Log. The purpose of filling out these food and medication records is to help better understand WHAT you are
Appendix 3c - 3 Day Food Intake Record & Medication Log Please keep a record of everything you EAT and DRINK for 3 days; 2 week days and one weekend day. Include all meals, snacks, and beverages, and the
More informationFish, Meat, Poultry, Dairy, and Eggs
Poultry, Dairy, Session 4 Background Information Tips Goals Assessment In an average WEEK, how many servings of these foods do you eat? Desirable Could be improved Needs to be improved 1. Fish, including
More informationContents. Chapter 1: What Is a Good Diet? Chapter 2: What Does a Good Meal Look Like? Chapter 3: Take It Slow... 10
Disclaimer You should consult your physician prior to starting this program particularly if you have any medical condition or injury that could prevent you from following this program. This program is
More informationYouth4Health Project. Student Food Knowledge Survey
Youth4Health Project Student Food Knowledge Survey Student ID Date Instructions: Please mark your response. 1. Are you a boy or girl? Boy Girl 2. What is your race? Caucasian (White) African American Hispanic
More informationNUTRITION FOR SOCCER: FUELING FOR OPTIMAL PERFORMANCE. Erika Carbajal, Sports Nutritionist
NUTRITION FOR SOCCER: FUELING FOR OPTIMAL PERFORMANCE Erika Carbajal, Sports Nutritionist 1 TOPICS TO BE COVERED Everyday nutrition Protein and carbohydrate needs Meal planning basics Pre-/post- workout
More informationm-neat Scoring System
m-neat Scoring System Points No. NUTRITION AWARENESS 1 Nutrition education material is available, up-to-date. 1 Yes=(1) No=(0) FOOD CENTER OR SNACK BAR 3 Available nutrition labeling of prepared items
More informationGoals for Eating Well, Living Well
Goals for Eating Well, Living Well Fruit/Vegetable servings per day (rainbow of colors) Dairy/Calcium-rich foods per day (1300 mg/day) Large servings of water per day Hours of screen time (texting, computer,
More informationAPPLIED KINESIOLOGY INTAKE FORM. Patient Name: Date: Date of Birth: Referred by: address: Day time phone number. Address CHIEF COMPLAINT:
APPLIED KINESIOLOGY INTAKE FORM Patient Name: Date: Age: Date of Birth: Referred by: Email address: Day time phone number Address CHIEF COMPLAINT: Describe other methods used to relieve discomfort (other
More informationLower your sodium intake and reduce your blood pressure
Detailed information on dietary sodium for public Lower your sodium intake and reduce your blood pressure www.lowersodium.ca Lower Your Intake and Reduce Your Blood Pressure The chemical name for salt
More informationEating Healthy on the Run
Eating Healthy on the Run Do you feel like you run a marathon most days? Your daily race begins as soon as your feet hit the floor in the morning and as your day continues you begin to pick up speed around
More informationNUTRITION & ACTIVITY TRACKER
NUTRITION & ACTIVITY TRACKER Date: to INFORMATION ABOUT MYSELF Name: Address: City: State: Zip: Phone: Height: Weight: Other: X 1-888-222-2542 Nutrition & Activity Tracker This record is designed to help
More informationEating Healthy with PSC. Erin Paice, RD, CD-N Hartford Hospital Transplant
Eating Healthy with PSC Erin Paice, RD, CD-N Hartford Hospital Transplant Objectives What does it mean to eat healthy? What are barriers to maintaining a healthy diet with PSC? How can we keep a healthy
More informationWeight Loss- Medical History Form
Weight Loss- Medical History Form Name: Age: Sex: M F Family Physician: Phone: May we contact this practitioner? Yes No Present Status: 1. Are you in good health at the present time to the best of your
More informationMiven Donato, DPT, DC
Miven Donato, DPT, DC 1314 Center Dr, #F Medford, OR 97501 541-857-2678 Comprehensive Medical In-take Questionnaire Form 5 of 5 Nutritional History, Lifestyle History, Social History Readiness Assessment
More informationPower of Protein After Surgery
Power of Protein After Surgery What is Protein? Protein is: An essential nutrient. Used to build things in our bodies such as muscle. Made up of 20 amino acids, or building blocks. 9 of the 20 amino acids
More informationPET/CT Patient Information
PET/CT Patient Information BC Cancer Functional Imaging Department includes BC s only two publicly funded PET/CT scanners. Located on the first floor of BC Cancer Vancouver Centre, the Functional Imaging
More informationLose It To Win It Weekly Success Tip. Week 1
Lose It To Win It Weekly Success Tip Week 1 Writing down your goals will keep you on track. Revise or add to your goals at any time. Start by setting a long-term weight loss goal. Next, set a goal for
More informationSupplemental Table 1: List of food groups
Supplemental Table 1: List of food groups Food groups names Food groups description Serving size definitions - Examples Fruits and vegetables Vegetables Fruits Whole vegetables All vegetables but soups,
More informationHealthy Food and Beverage Policy Position Statement Policy Catered Meals Employee Snack Food and Beverages Meetings, Functions and Events
Healthy Food and Beverage Policy Position Statement Healthy eating and drinking are fundamental to good health, helping individuals feel and handle stress better, achieve optimal work performance and have
More informationHeart Healthy Living. Steven Rudner, BS Nutrition & Dietetics Dietetic Intern, Sodexo Allentown.
Heart Healthy Living Steven Rudner, BS Nutrition & Dietetics Dietetic Intern, Sodexo Allentown www.dieteticintern.com www.sodexo.com Heart Healthy Living 1. Good Nutrition 2. Physical Activity 3. Behavior
More informationFood & Fun Afterschool 2 nd Edition Parent Communications. Unit 4: Fats in Foods. About Parent Engagement. Parent Engagement Activities
Food & Fun Afterschool 2 nd Edition Parent Communications Unit 4: Fats in Foods About Parent Engagement Engaging with families in after school time is associated with increased family involvement in children
More informationNutrition for Rehab Patients
Nutrition for Rehab Patients Michelle Ray, RD Michelle Ray, RD Michelle Ray MS, RD, LDN Making healthcare remarkable Why is nutrition important for our patients? Adequate nutrition protects quality of
More informationFecal Fat Test Diet Preparation
Fecal Fat Test Diet Preparation Purpose Malabsorption is a medical condition that means fat in the diet (and also proteins, carbohydrates, minerals, and vitamins) may not be absorbed properly. Absorption
More informationNutrition History and Questionnaire
Nutrition History and Questionnaire Florida Surgical Weight Loss Center Last Name: First Name: Address: e-mail address: DOB: Occupation: Highest Education Level Completed: Grade School High School College
More informationThe Grocery Excursion
Transparency/Blackline Master Grade 5 Day 38 Standard 5.NBT.7 The Grocery Excursion Name: Date: You are visiting your grandparents for one week and have been given $200 to purchase groceries for the three
More informationHeart Healthy Nutrition. Mary Cassio, RD Cardiac Rehabilitation Program
Heart Healthy Nutrition Mary Cassio, RD Cardiac Rehabilitation Program Today s Topics Healthy Eating Guidelines Eating Well with Canada s Food Guide Balanced Eating Heart Healthy Nutrition Increased blood
More informationHEALTH HISTORY/INTAKE
HEALTH HISTORY/INTAKE Name: Birthdate: Date: / / Address City, State, Zip Email: Phone (day): (evening): Billing address, if different: Best time to call: Preferred form of communication: Weight: Height:
More informationPatient Registration Please fill out and bring to your first visit. (Please Print) PATIENT INFORMATION. P.O. Box: City: State: ZIP Code:
Nutrition Works LLC 805 Stevens Avenue Portland, Maine 04103 (207) 772-6279 Fax (207) 347-4281 Susan Quimby, R.D., L.D. Judy Donnelly, R.D., L.D. Kim Norbert, M.S., R.D., L.D. Patsy Catsos, M.S., R.D.,
More informationHealthy Hearts, Healthy Lives Health and Wellness Journal
Healthy Hearts, Healthy Lives Health and Wellness Journal Healthy Hearts, Healthy Lives You Are in Charge You can prevent and control heart disease by making some lifestyle changes. Keeping your journal
More informationNutrition Through the Stages of CKD Stage 4 June 2011
Nutrition Through the Stages of CKD When you have chronic kidney disease, nutrition is an important part of your treatment plan. Your recommended diet may change over time if your kidney disease gets worse.
More informationNutrition: Hypertension Nutrition Therapy
Nutrition: Hypertension Nutrition Therapy WHY WAS NUTRITION THERAPY PRESCRIBED? Hypertension (High Blood Pressure) Nutrition Therapy using the DASH-sodium meal plan reduces sodium (salt) in your meal plan
More informationMEDITERRANEAN EATING GRANT CEFALO RD, MDA, CD, CNSC
MEDITERRANEAN EATING GRANT CEFALO RD, MDA, CD, CNSC OBJECTIVES Why is it needed? Current trends Review the Mediterranean Lifestyle Discuss application of this lifestyle MANY OF AMERICAN S EATING PATTERNS
More informationMr. Ms. Mrs. (circle one) First Name: MI: Last Name: Address: Address: City: State (Province): Zip (Postal Code):
Center for Metabolic Health and Weight Management Metabolic Health and Weight Management Program Intake Form In order for us to process your enrollment form quickly and accurately, please print legibly
More informationFood Portions. Patient Education Section 9 Page 1 Diabetes Care Center. For carbohydrate counting
Patient Education Section 9 Page 1 For carbohydrate counting This handout answers the following questions: What s the difference between a portion and a serving? How do I know how big my portions are?
More informationClient Intake Form. General Information. Telephone Home: Work: Cell: How would you prefer to be contacted? Emergency Contact: Ph:
General Information Name: Telephone Home: Work: Cell: Mailing Address: Client Intake Form Date: Email: How would you prefer to be contacted? Who referred you? Gender: M F Date of Birth: Primary Doctor:
More informationUniversity of Mississippi Medical Center Dietary Guidelines following Obesity Surgery
University of Mississippi Medical Center Dietary Guidelines following Obesity Surgery The operation that you had will help you control the amount of food you eat. This will help you lose weight. It is
More informationHealthy Weight Guide A Guide for Parents of Children With Special Needs
Healthy Weight Guide A Guide for Parents of Children With Special Needs These suggestions can help your child reach and stay at a healthy weight. (The consistency of the foods listed may be changed to
More informationHealthy Meeting & Event Guidelines. Second Edition
Healthy Meeting & Event Guidelines Second Edition Contents Healthy Meeting & Event Guidelines 4 6 7 8 10 11 Four Guidelines for a Healthier Meeting Environment Tips for Selecting Low-Fat Foods Tips for
More informationIn this issue: 2 How High Blood Pressure Harms Your Body 3 5 Ways to Lower Your Blood Pressure Without Medication
Newsletter MAY 2014 In this issue: 2 How High Blood Pressure Harms Your Body 3 5 Ways to Lower Your Blood Pressure Without Medication 4 DASH to Lower Blood Pressure 6 10 Questions (and Answers) About Monitoring
More informationHealthy Foods for my School
, y Healthy Foods for my School Schools are an ideal place for children and youth to observe and learn about healthy eating. Children learn about nutrition at school and they often eat at school or buy
More informationEmpower Yourself! Learn Your Cholesterol Number NATIONAL INSTITUTES OF HEALTH
/vat/va Empower Yourself! Learn Your Cholesterol Number /vat/vat/vat/ vat/vat/vat/v at/vat/vat/va t/vat/vat/vat /vat/vat/vat/ vat/vat/vat/v at/vat/vat/va t/vat/vat/vat /vat/vat/vat/ vat/vat/vat/v at/vat/vat/va
More informationLow-Fat Diet and Menu
Low-Fat Diet and Menu Intended use The low-fat diet is intended for use by individuals who have maldigestion or malabsorption of fat, such as small bowel resection, pancreatic disease, gastroparesis, fatty
More informationHistory of the. Food Guide Systems
History of the Food Guide Systems 1940 A guide to good eating, the basic 7 Focus on nutritional adequacy, specific servings from each food group 1956-1970 Food For Fitness: Daily Food Guide Basic 4 1979
More informationPHOSPHORUS AND DIALYSIS
WHY IS IT IMPORTANT TO MONITOR YOUR PHOSPHORUS? Healthy kidneys excrete phosphorus from your body. But phosphorus builds up in the blood when kidneys fail, which causes calcium to come out of the bones.
More informationStep Up and Celebrate
Step Up and Celebrate Physical Activity Physical Activity Healthy Eating Goals Met Rewards Goals Met 1. 1. Handout 12-1 Healthy Eating Rewards 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. Choose an appropriate reward
More informationEGEA MEDICAL WEIGHT LOSS CENTER. Name: Age: Sex: M F. 6. History of Diabetes? Yes No At what age:
EGEA MEDICAL WEIGHT LOSS CENTER Medical History Form Name: Age: Sex: M F Primary Care Physician: Home Phone : Present Status: 1. Are you in good health at the present time to the best of your knowledge?
More informationCity: State: Zip: Age: Height: Current weight: Weight 6 months ago: Employer: Work #: Ext:
1 Last Name: First Name: Middle Initial: Address: Apartment #: City: State: Zip: Home #: Cell #: Email: How did you find us? Patient (who) : Doctor (who) : Staff (who) : Date of Birth: / / Gender (circle
More informationFOCUS ON CONTROLLING WHAT YOU CAN CONTROL AND ACCEPTING WHAT YOU CANNOT CONTROL.
Nutrition Guide Disclaimer: Please discuss with your physician or healthcare provider before starting this program. The information provided does not intend to replace the advice of a medical professional.
More informationNUTRITION 101. Kelly Hughes, MS, RD, LD Texas Health Presbyterian Hospital Allen (972)
NUTRITION 101 Kelly Hughes, MS, RD, LD Texas Health Presbyterian Hospital Allen (972) 747-6149 KellyHughes@texashealth.org Alastair & Wendy Hunte Health & Wellness Coaches Nutrition Avenue (214) 509-8141
More informationSample Well-being Assessment
Sample Well-being Assessment This assessment addresses the following eight categories, as well as the importance, readiness, and confidence in each category: Energy Stress Management Life Balance Weight
More information