Session Info

Date:

Visit type:

New patient

Telehealth

Duration (min):

CPT / billing code:

Subjective — Nutrition Intake

Chief nutrition concern:

Health & nutrition goals:

Weight history:

Food allergies / intolerances:

Dietary preferences / restrictions:

Current dietary pattern:

Omnivore

Vegetarian

Vegan

Mediterranean

Paleo

Ketogenic

Gluten-free

Other (describe)

Diet & GI Assessment

Dietary Pattern Snapshot

Recall Window

Recall Method

Seven Day Recall

Recall Start

YYYY-MM-DD

Recall End

YYYY-MM-DD

Recall Window Days

days

Subjective ratings

Hunger

Rate how urgently your body is signaling a need for fuel before meals. 0 is a physical emergency (shaky/weak); 5 is neutral; 10 is constantly ravenous.

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Satiety

Rate the physical sensation of fullness after meals. 0 is empty/starving; 6 is comfortably satisfied; 10 is painfully full or sick.

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Cravings

Rate the intensity of your desire for specific foods. 0 is no specific desire; 5 is present but ignorable; 10 is an overwhelming 'must-have-now' urge.

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Post-Meal Energy

Rate your energy level 30–60 minutes after eating. 0 is a 'food coma' or extreme fatigue; 5 is stable/steady; 10 is highly energized.

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Food Group Intake Frequencies

Food Groups List Add Food Group

No food groups recorded.

Nutrient Aggregates

kcal

Protein (g)

Carbs (g)

Fat (g)

Fiber (g)

Added sugar (g)

Sodium (mg)

Nutrition Report Document

No nutrition report attached

Notes

Dietary patterns, dietary restrictions, nutritional compliance...