Clinical Application utrition Screening, Assessment, and Intervention
Student Name:
Part 1 istorical and Nutrition Assessment
Collect Information
This outline is for you to collect information from your client !sk them about all areas during
the interview. You will calculate BMI and determine BMI classification after your interview.
Your written summary should be an evaluation/assessment of this information.
Medical History
Age:
Height/Weight:
BMI:
BMI Classification:
Current Complaints:
Past Medical Conditions:
Surgical History:
Family Medical History:
Allergies:
Mental/Emotional Health Status:
Medication and Supplement History
Prescription Drugs:
Over-the-Counter Drugs:
Dietary and Herbal Supplements:
Personal and Social History
Employment Status:
Education Level:
Socioeconomic Status:
Cultural/Ethnic Identity:
Religious Beliefs:
Home/Family Situation:
Cognitive Abilities:
Use of Tobacco or Illegal Drugs:
Food and Nutrition History
Typical Food Intake (Number or Meals and Snacks per Day):
Alcohol Consumption:
Dietary Restrictions:
Food Allergies and Intolerances:
Nutrition and Health Knowledge:
Food Availability:
Physical Activity and Exercise Habits:
Part 1 valuation and Assessment of the information collected
In the space below write a minimum of a 1-page evaluation of your findings.
Hint: Do not just repeat the details from the outline. Provide an evaluation.
What does the information tell us about their current health and their risk of health issues and
chronic illnesses in the future? What recommendations do you have?
You should be able to evaluate what health risks a person has, what can they do about it? etc—hat are the possibilities for diseases or potential nutrition-related problems based on the
patterns of disease, supplements, diet, physical activity and lifestyle habits? How does their BMI
play a role in their health risk? How does their family history play a role in their health risks or risk
of chronic diseases? EtcŠPart 2 24-Hour Recall
Complete the tables below. Ask your client about their intake for a 24-hour period.
Table 24-Hour Recall
**One food/beverage item per row, the cells will expand for items with long names or descriptions**
** Use the MyPlate website to see what counts in each food group and portion**
https://www.myplate.gov/eat-healthy/what-is-myplate
Meal or
Snack/
Time of
Day
Example
8:00 am
8:00 am
Totals
Food or Beverage
Consumed/Preparation
Method
Quantity or
Amount
Consumed
Oatmeal, cooked
Fresh Blueberries
up
up
Fruit
(Cups)
Veg.
Grains
Protein Dairy
(Cups) (Ounces) (Ounces) (Cups)
1 oz
ups
Table – Compare Intake to the My Plate Plan Recommendations
** This should use the My Plate Plan values for the Calorie level estimated for your Client**
Food Group
**My Plate Plan
Recommended
Number of
Servings per Day
Total Number of
Servings
Consumed in
24-Hour Recall
Number of
Brief Suggestions
servings still
(Full discussion
needed each Day
provided in
Evaluation
below)
Fruit (Cups)
Vegetables
(Cups)
Grains (Ounces)
Protein (Ounces)
Dairy (Cups)
Part 2 valuation of Intake
In the space below write a 1-page evaluation of your findings (minimum 3-5 full paragraphs),
with detailed evaluation and specific suggestions for improving their diet or including a wider
variety of foods. **This is meant to be a simulation, not a counseling session for your client,
your response is for the assignment submission only**
Hint: Summarize your findings of how their intake measures up to their My Plate Plan, discuss what
is needed to improve their intake and offer specific suggestions of foods to include to improve the
quality of their diet or meet the My Plate Plan recommendations for each Food Group.
Discuss each food group and number of servings your client still needs and offer suggestions for
changes in food intake to meet the minimum number of servings from each food group while
controlling calories. What is good about their diet, what is inadequate and what suggestion do you
have to improve it? Are they at risk for potential nutrition problems?

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