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 consult Name* 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 What type of driver are you* PSD TNT Trainer solo driver team driver in house Are you in the Diabetes program* Yes No What is your last week's average of BGs, or a recent fasting BG Assessment/ Engaging Engage – build rapport, use open ended questions, uncover values and hopes, offer compassionate value-based reflections maintaining curiosity about your client --Type any relevant info for the ENGAGING sectionIn general, what are your goals?* Lose weight/fat Learn how to make better nutrition habits Gain weight Learn more about nutrition Maintain weight Add muscle Improve physical fitness Look better Feel better Have more energy and vitality Get control of eating habits Get stronger Manage a chronic disease Check all that apply.Of the above goals, which is most important to you and why? Do you have a past hx of trying to reach similar goals?*Focusing section- – bring the conversation to the topic at hand & elicit personal concerns, related symptoms, severity, screening results and wellness indicators Have you been diagnosed (currently or in the past) with any significant medical conditions and/or injuries and do you have any medications, either OTC or RX that interact with your lifestyle?* Yes No List conditions/ diagnoses and meds if applicableAre there any foods you will not eat because of intolerances or allergies? Are there any foods you will not eat because you dislike them?*What is a typical day of eating look like for you lately?*What fluids do you drink throughout the day?*Evoking sectionexplore reasons for and against change, then help to elaborate on reasons for change, use pros and cons, double sided reflections, readiness rulers and wellness recommendations Right now, how would you rank your overall eating, nutrition habits on a scale of 1-5?ExcellentPretty goodNeutralNot so greatTerribleHow would you rank your motivation to change your eating habits on a scale of 1-5ExcellentPretty goodNeutralNot so greatTerribleNotes on coping, stress managementOn average, how many hours per night do you sleep?* 4 or fewer hours 5 hours 6 hours 7 hours 8 hours 9 hours 10 hours How ready, willing, and able are you to change?How READY are you to change your behaviors and habits from 1-5?CompletelyAlmost thereNeutralKind ofNot at allHow WILLING are you to change your behaviors and habits from 1-5?CompletelyAlmost thereNeutralKind ofNot at allHow ABLE are you to change your behaviors and habits from 1-5?CompletelyAlmost thereNeutralKind ofNot at allWhat would be the biggest benefit to your life if you made a change for your health? Diagnosis/ Planning section– collaborate on the ways in which change will happen choosing specific, attainable goals, elicit commitment for health directed behaviors - note specific - statements as to where, when, with whom and how and schedule follow-upSummary of goals/action steps/ notes for driver to send via email
