MEDICAL NUTRITION THERAPY CHART AUDIT

MEDICAL NUTRITION THERAPY ASSESSMENT and OUTCOMES: HYPERLIPIDEMIA Dear Patient: Please provide as much information as possible in the SHADED areas PATIENT NAME: M F DOB: AGE: PHYSICIAN: ADDRESS: TELEPHONE: ID NUMBER: PREVIOUS MNT (NO. HRS): __MEDICARE B __NON-MEDICARE stTODAY’S DATE: 1 Visit Assessment Values GOALS DATE:________ (3 - 12 Month Follow-Up MNT OUTCOMES) Usual Blood Glucose: Total cholesterol: LDL-cholesterol: HDL-cholesterol: Triglycerides: Waist circumference (inches around): Blood pressure: Ht: Wt: Recently gained lost _______pounds Medications: cholesterol blood pressure water pill aspirin blood thinner Plus other medications: Dietitian Use OUTCOMES Tobacco use: Type: Amount per day: or amount per week: Exercise: Did doctor OK exercise? yes no Do you exercise? yes no Type: Minutes per day: Number of times per week: Medical problems: Digestive and/or ...