Dietician Template

History of Presenting Illness

[Provide a detailed narrative of the patient's presenting illness including diagnosis, disease history, previous hospitalizations, diagnostic procedures (e.g., colonoscopy), treatments tried, and current disease status. Include any extra-intestinal manifestations and relevant imaging or test findings. Mention any referrals related to the condition.] (Write in chronological Order) For Example: 30-year-old diagnosed with Crohn's disease (colonic involvement with rectal sparing), likely had CD prior to April 2024 official diagnosis. In Feb 2023 was hospitalised and had a colonoscopy that showed multiple large and deep ulcers (larger than 2cm) throughout the colon. Received treatment from chiropractor and acupuncturist however her abdominal symptoms continued. September 2023 - elevated fecal calprotectin - 4000 - but was hesitant to start medical therapy so didn't end up starting Entyvio until June 2024. Colonoscopy in 2024 - severe colonic disease with rectal sparing Extra-intestinal manifestation - oral sores, joint pain and erythema nodosum IUS - severe transmural inflammation throughout the colon with risk of complications and need for emergency surgery, normal terminal ileum. Repeat Oct 1st 2025 Referred to see a dietitian to provide dietary advice for severe active colonic CD.

Current Vitamins / Nutritional Supplements

[Present all current vitamins and nutritional supplements in a concise list format. Include name, dosage, and frequency. Use medical abbreviations and shorthand as appropriate. Do not use complete sentences.] For example: - B complex liquid, folate - Vitamin D drops, 2000 IU/day

Medications

[Present current medications in a concise list format. Include medication name, start date, and brief notes on effectiveness or changes. Use medical abbreviations where appropriate. Do not use complete sentences.] For example: - Infliximab, started June 2025 - Entyvio, started June 2024; loss of response 2025

Lab Work

[Present recent lab results relevant to the patient’s condition in a concise list format. Include test name, value, reference range, and note abnormalities. Use medical abbreviations and shorthand.] For example: - Albumin 33 (35-50) low - ALP 144 (35-120) elevated - B12 455 normal - CRP 61.1 (<5) elevated - Fecal calprotectin 7120 (<150) markedly elevated (6/27/25)

Weight Status

[Present weight and height data in a concise list format. Include current weight, usual weight, height, and note any weight changes or trends. Do not use complete sentences.] For example: - Current weight 60 kg - Usual weight 65 kg - Height 174 cm

Gastrointestinal Symptoms

[Describe the patient's current gastrointestinal symptoms including bowel movement frequency, consistency, any difficulties such as constipation or straining, and changes in symptoms over time. Include any relevant lifestyle impacts.] For Example: Passing 2-3 BM per day - formed/soft. Constipation and straining to pass BM at times. At the end of June she was on bed rest as she was feeling so unwell. Feeling a lot more like herself now. Energy levels and appetite have significantly improved over the last 6 weeks or so

Lifestyle Notes

[Present lifestyle habits in an extremely concise list format. Do not use complete sentences. Include only essential information such as exercise frequency and types, sleep quality, and smoking status.] For example: - Exercise: she exercises 3-4 times per week . Runs, HIIT workouts and walks regularly. - Sleep: she reports she feels well rested on most days - Smoker: Not smoker

Allergies, Sensitivities and Dietary Restrictions

[Present any known allergies, food sensitivities, or dietary restrictions in an extremely concise list format. Do not use complete sentences. Only include essential information.] [Otherwise, state "No current restrictions."]

Relationship with Food

[Present patient's relationship with food in an extremely concise format. Use list form. Do not use complete sentences. Include only essential information such as attitudes, enjoyment, and relevant psychological or behavioral notes.] For example: - Positive relationship with food currently - enjoys food and cooking. - Patient reports they have a good relationship with food .

Usual Diet

[Provide a detailed description of the patient's usual dietary intake including number of meals per day, typical foods consumed at each meal (breakfast, lunch, dinner), snacks, and fluid intake. Include notes on eating behaviors such as pace and distractions. in the following format: - [Specify the number of meals consumed per day] - [Specify the number of snacks consumed per day] - [Indicate if there is any distracted eating] - [Describe the pace of eating] Breakfast: [List typical breakfast options, including any specific ingredients or variations] Lunch: [List typical lunch options, including any specific ingredients or variations] Dinner: [List typical dinner options, including any specific ingredients or variations] Fluids: [List types of fluids consumed regularly] Snacks: [List typical snack options, including any specific ingredients or variations]] For Example: • she consumes 3 per day • she consumes 2 per day. • she reports no distracted eating • she reports a steady pace of eating. Breakfast: Pancakes (homemade) with raspberry sauce OR 2x bread with cheese and jam OR avocado toast with a slice of cheese Lunch: Sandwich OR soup OR scrambled/boiled eggs OR leftovers Dinner: Meat or fish with rice or pasta or potatoes with salad or vegetables OR soup Fluids: Water, herbal teas, homemade kombucha Snacks: Ice cream with raspberries, OR watermelon, carrots, cucumbers

Nutrition Assessment

[Present nutrition assessment findings and advice in an extremely concise list format. Do not use complete sentences. Include only essential information related to nutrition and IBD.] For example: - General nutrition advice provided - IBD-specific dietary recommendations given

Nutrition Recommendations

[Present specific nutrition recommendations in a concise list format. Use bullet points. Do not use complete sentences. Include supplements, dietary modifications, and key advice on food types or nutrients to emphasize or limit.] For example: - Advised to start taking 2000IU of vitamin D3 daily - Discussed the importance of high omega 3 and fibre foods during remission and disease flare (change to soluble fibres and resistant starch) - Discussed importance of incorporating fermented foods in to diet and limit processed foods (food additives) to support a healthy gut microbiome

Handouts / Resources Given

[Present educational materials/resources in a concise list format. Use brief phrases without complete sentences. Include only essential topics.] For example: - Nutrition during a flare - Nutrition in remission

Monitoring and Evaluation

[Present follow-up plan in a concise narrative format. Include whether follow-up is scheduled or optional and patient instructions regarding future concerns.] For example: A follow-up appointment is not needed at this time. Test Patient is aware that she can book a follow-up appointment in the future if she has further nutrition questions or concerns.