CLIENT PROGRESS NOTES

Complete within 24 hours of meeting with client and upload into your dropbox.
Client initials:AR
Date: 10/22/14
Assessment: Age: 20 Race: W
Gender: F Reason/concerns: healthy eating, reinforce learning, exercise,
desired weight loss
Classification: undergrad/grad/staff, lives on campus/dorm/apartment
Height: 54 Weight: 13 BMI: 23.2 Ideal Weight(or adjusted): 120 Preferred Weight: 130 Weight Hx: -----Personal Medical Hx:
---------Family Medical Hx
---------Activity level: Exercised every day for 1-1.5hr in the summer, but is now busy with school
Alcohol consumption: a few drinks once every few weeks Smoker? no Sleep patterns: 5-8hr/night Stress: 6
Medications/Supplements none
Previous diet efforts: none
Behavior: 24 hour intake vs. ChooseMyPlate goals
Meat /Beans Discretionary
Calories
Grains
Vegetables
Fruits
Dairy
Recommended
2000
6oz
2 cups
2 cups
3 cups
5 oz
258
Actual
857
3 oz
0
Fruit bowl
Cheese,
3 oz, deli
211
wheat
milk w/
turkey
bread,
cereal
cereal
Describe food habits/patterns here: Wants to eat more vegetables, but has trouble finding different vegetable options
around campus. Mostly only eats at West end. Seems to be determined to complete goal, but is picky with vegetables and
seems to provide excuses as to why she cannot follow my suggestions. Seems like client is in the contemplation stage, but
is willing to make small changes. Would like to exercise more, but finds it difficult to have enough time or motivation. Talked
about strategies to incorporative physical activity into daily life. Says she is hungry when she only eats a fruit bowl for lunch,
but is unsure of what else she can eat that is healthy.
Attitude: Positive, friendly attitude. Seems open to suggestions, but struggles with implementation.
Knowledge: rates nutrition knowledge at an 8. HNFE science major.
Diagnosis: inadequate energy intake r/t insufficient food choices AEB low caloric intake of around 850 calories.
Undesirable food choices r/t very low intake of vegetables AEB 24-hr recall.
Intervention: goals,strategies and handouts given
1. Exercise for 30 minutes, 2 times a week. Every Tuesday plus 1 other free day.
2. Add more vegetables to diet by using vegetables as snacks
3. Increase overall caloric intake, especially at lunch.
M/E Monitoring and evaluation: follow-up plans
I will check in with her in a few weeks to see how her plans are going and if she would like to meet again.
Nutrition Counselors Signature: Kristen Ellis

Follow-up notes should be entered at the top of the original note then replace the original note in your dropbox.

Submit the electronic version within 24 hours of client meeting using only initials using Scholar Dropbox