Initial Assessment for Functional Nutrition Template

Functional Nutrition Initial Note
Background:
The patient is a 35-year-old female experiencing fatigue and weight gain. Her medical history includes hypothyroidism and hypertension. She is currently taking levothyroxine 100 mcg daily and lisinopril 10 mg daily. Previous dietary efforts involved low-carb diets with minimal success. Notable symptoms include bloating and irregular bowel movements. Nutrition Goals: To lose 10 kg over the next 6 months and enhance energy levels.
Diet History/Routine:
- Frequently skips breakfast
- Consumes a large lunch, typically fast food
- Dinner often consists of pasta or rice-based meals
- Evening snacks include chips and chocolate
- Previous diet attempts: Low-carb diet
- Disordered eating thoughts: Emotional eating during stressful times
Dietary recall:
Breakfast - Skipped
Lunch - Cheeseburger and fries
Dinner - Spaghetti with meat sauce
Snacks/Sweets - Chocolate bar and crisps
Diet pattern: 2 meals and 2 snacks daily
Hydration: 1 litre of water daily, drinks 2 cups of coffee and 1 can of soda
Alcohol Intake: 2 glasses of wine on weekends
Exercise:
- Walks 30 minutes, 3 times a week
- No physical limitations
- Interested in starting yoga
Lifestyle/social factors:
- Occupation: Office manager, 9-5 schedule, works onsite
- Sleep quality: Fair, 6 hours a night, disrupted by snoring
- Stress levels: High, occasionally uses meditation apps
Weight History:
- Current weight: 85 kg, goal weight: 75 kg
- Weight trajectory: Gained 10 kg over the past 2 years
FHx: Family history of diabetes and obesity
MHx: Hypothyroidism, hypertension
SXS:
- Fatigue
- GI: Bloating, irregular bowel movements
Medications:
- Levothyroxine 100 mcg daily
- Lisinopril 10 mg daily
Supplements:
- Multivitamin daily
Nutritional Imbalances/Labs: Elevated TSH levels
Food Allergies/sensitives: None
Food Preferences: Prefers spicy foods
Nutrition Assessment:
Summary:
The patient is a 35-year-old female with a history of hypothyroidism and hypertension, presenting with fatigue and weight gain. She leads a sedentary lifestyle and has irregular eating habits, which contribute to her current health concerns. Her objective is to lose weight and boost energy levels through dietary modifications and increased physical activity.
Assessment:
- Female, 35 years old, born on 1 November 1989
- Personal history: Hypothyroidism, hypertension, family history of diabetes and obesity
- Anthropometrics: Height 165 cm, weight 85 kg, BMI 31.2, weight gain of 10 kg over 2 years
- GI: Bloating, irregular bowel movements
Diagnosis:
- Nutrition diagnosis: Overweight related to excessive energy intake as evidenced by BMI of 31.2 (ICD-10: E66.3)
- PES statement: Overweight related to excessive energy intake as evidenced by BMI of 31.2
Education/Counseling:
- Discussed guidelines on balanced diet, importance of regular meals, and physical activity
- Counseling on stress management techniques
- Provided handouts on meal planning and portion control
Intervention:
Nutrition Prescription:
- Calorie goal: 1500 kcal/day, Protein goal: 60 g/day, Carbohydrate goal: 200 g/day, Fluid goal: 2 litres/day
- Food journaling encouraged
- Nutrition goals: Weight loss of 10 kg, improved energy levels
- Nutrition action plan: Incorporate more fruits and vegetables, reduce fast food intake
Lifestyle:
- Exercise action plan: Start yoga classes twice a week
- Stress/sleep action plan: Improve sleep hygiene, continue meditation
Supplements:
- Continue multivitamin
Labs:
- Monitor TSH levels every 3 months
Monitoring and Evaluation: weight/BMI, labs/ symptoms
- Progress evaluation: Track weight loss, energy levels, and TSH levels
- Follow-up care: Schedule follow-up in 3 months
Topics/Concerns to address next visit:
- Meal planning
- Barriers to success
- Coordination of nutrition care with other healthcare professionals if needed