NUTRITION COUNSELING SCORING FORM
First Name:
Last Name:
Student ID:
History Checklist
CC: I don't know what to eat, or how to prepare it!
HPI -History of diet: Used to eat well when wife and then daughter prepared good meals
Progression: Now on my own with few cooking skills
Daily diet: Now it?s fast food; cold cereal
Barriers: Lack of skills in planning and cooking
Assets for change: I like eating good food and am eager to change
PMH: History of depression
Medications: Treated with anti-depressant; doing well
Allergies: No allergies to food or medications
Family history: Mother: diagnosed with Type II diabetes at age 63, not overweight, father has untreated depression, still alive, age 73.
Psych history: No history of obesity or eating disorders
Social history: Lives alone (divorced, had full custody of daughter because divorce happened on grounds of her mother?s alcohol abuse),
Finances: Has insurance, landscaper is financially stable
Social Support: A happy loner; talks to Dad and daughter weekly
Alcohol: Does not drink
Smoking: Not a smoker
Counseling Checklist
Student affirms the importance of good nutrition for good health
Student asks about resources: community college cooking class; daughter's help when she comes home
Student recommends a healthier options for one meal a day
Student suggests a contract for patient to get the initiative to sign up for cooking classes, and to ask grocers at the store for suggestions of healthier cuts of meat
Student shows support, and emphasizes her role as a support-provider, and that he can call the office with questions
Student recommends that patient sees a dietician to get more tailored recommendations, it is covered by patient's insurance
Student suggests a log of daily food choices to take to dietician
Student plans for follow-up.
MIRS
Opening
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Elicits Spectrum of Concerns
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Negotiates Priorities and Sets Agenda
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Organization
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Pacing of Interview
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Types of Questions
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Summarizing
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Lack of Jargon
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Verification of Patient Information
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Verbal Facilitation Skills
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Non-Verbal Facilitation Skills
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Empathy and Acknowledging Patient Cues
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Patient's Perspective (Beliefs)
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Impact of Illness on Patient and Patients Self-Image
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Support Systems
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Patient's Education and Understanding
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Assess Motivation for Changes
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Achieve a Shared Plan
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Encouragement of Questions
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Closure
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