Follow up nutrition consult tracking form This is a nutrition consult form for drivers or in-house to be filled out by dietitian during consult time for tracking purposes. Nutrition follow upName* First Last Phone*Email* Truck # (if you want us to contact you via QC messages/reminders) I will send you a summary and goal list of what we talk about today. How do you prefer me to contact you and send you that info?* Email text (google voice) QualComm On paper are you in the Diabetes Program?*yesnoWhat is your last week's average of BGs, or a recent fasting BG Are your goals the same as when we last talked or have they changed?*Any new recent medical concerns?* Yes No List conditions/ diagnoses and meds if applicableRank yourself currently on your eating habits from 1-5ExcellentPretty goodNeutralNot so greatTerribleAny change in your eating habits since we last talked?* yes no yes, but then stopped What is a typical day of eating look like for you lately? And what fluids do you drink throughout the day?*What do you want to work on today?*How ready, willing, and able are you to change?How READY are you to change your behaviors and habits?CompletelyAlmost thereNeutralKind ofNot at allHow WILLING are you to change your behaviors and habits?CompletelyAlmost thereNeutralKind ofNot at allHow ABLE are you to change your behaviors and habits?CompletelyAlmost thereNeutralKind ofNot at allWhat do you expect from me as your dietitian to help you make changes?*Summary of call to review with clientSummary of goals/action steps/ resources to send to driver
