Bariatric Surgery Nutrition Evaluation (Pre-Op)

Date: [Encounter date]

Time: [Start time] – [End time]

Author: [Author name, credentials (e.g., RDN, LDN)]

Referral Source: [Referring clinician or service]

Planned Procedure: [SG / RYGB / BPD/DS / SADI-S / Adjustable gastric band / Revision / TBD - to be confirmed by surgical team]

Anticipated Surgery Date: [Date / TBD - to be confirmed by surgical team]

Program Visit Status: [Visit X of Y / Not part of multi-visit program]

Reason for Visit

[Patient's reason for today's visit and RDN's clinical focus for this session] (2–3 sentences covering items such as diet history review, readiness assessment, pre-op behavior targets, and/or post-op diet education.)

Nutrition Assessment

Anthropometrics & Weight History:

• Measured/chart-derived: [Current weight with date and source], [Height], [BMI], [Baseline program weight], [Progress toward pre-op target] (Include program weight and target only if applicable.)
• Patient-reported: [Highest adult weight], [Recent weight trend over 3–12 months], [Summary of prior medically supervised weight-loss attempts]

Relevant Medical History: (Problem-oriented list of conditions affecting diet tolerance, perioperative risk, or micronutrient needs. Include only applicable items.)

• [Diabetes/prediabetes status and most recent A1c]
• [GI conditions: GERD, nausea/vomiting, prior GI surgery, motility issues, dysphagia]
• [Renal/hepatic disease with stage or functional status]
• [Obstructive sleep apnea diagnosis and treatment adherence]
• [Dental/oral issues impacting chewing]
• [Other relevant conditions]

Medications & Supplements:

• [Medications impacting weight, glycemia, GI function, or nutrient absorption]
• [Current vitamins/minerals including bariatric products: product, dose, frequency, adherence]
• [Substance use: alcohol intake pattern; tobacco/nicotine use and cessation status]

Labs & Micronutrient Status:

• Available results: [Labs with dates, values, and interpretation] (Include procedure- and patient-specific labs: CBC, CMP, iron studies, B12, folate, vitamin D, thiamine, others as indicated.)
• Pending/not yet obtained: [Outstanding labs with plan for completion and timeframe]
• Micronutrient risk factors: [Diet quality concerns, vomiting history, PPI use, prior deficiencies, heavy menses, malabsorption risk, alcohol intake] (Include only if risk factors present.)

(If baseline labs are incomplete, state: "Micronutrient status cannot be confirmed without baseline labs" and document next steps. Do not document clearance without required lab documentation.)

Diet History: [Brief narrative summary of usual intake pattern and day-to-day variability]

• Meal timing & pattern: [Typical times, frequency, skipped meals]
• Protein sources: [Common sources and approximate portions]
• Fruits/vegetables: [Frequency and variety]
• Beverages: [Water intake; sugar-sweetened beverages; juice; caffeine; carbonation; alcohol]
• Restaurant/takeout: [Frequency and typical choices]
• Snacking/grazing: [Pattern and triggers]
• Allergies/intolerances: [List / Denies food allergies]
• Cultural/religious dietary patterns: [Relevant practices] (Include only if applicable.)
• Food records reviewed: [Dates reviewed and concordance with verbal recall] (Include only if records were reviewed.)

Eating Behaviors & Readiness:

• Portion awareness & pace: [Observations]
• Emotional eating / loss-of-control episodes: [Presence, frequency, triggers; referral status if indicated]
• Meal planning & preparation skills: [Capabilities and supports]
• Self-monitoring: [Food logging method and consistency]
• Understanding of post-op concepts: [Protein-first, liquid separation, chewing rules; teach-back results]
• Support system: [Household support, peer/community resources]
• Readiness determination: [Specific observations supporting readiness or areas requiring further preparation] (Justify with objective findings such as demonstrated teach-back, consistent food logs, or documented behavior changes.)

Psychosocial Factors: [Food insecurity, financial constraints for protein foods or supplements, transportation, health literacy, preferred learning format] (Include only when barriers exist. Use neutral language.)

Assessment Summary: [Key strengths, primary risks/barriers (behavioral, micronutrient, practical), and immediate priorities for intervention] (3–5 sentences.)

Nutrition Diagnosis

• [PES Diagnosis 1: Problem related to Etiology as evidenced by Signs/Symptoms]
• [PES Diagnosis 2] (Include only if applicable.)
• [PES Diagnosis 3] (Include only if applicable.)

(Order by bariatric impact. Do not diagnose micronutrient deficiency without lab confirmation; use "Risk of inadequate micronutrient intake" when based on dietary pattern alone. If no diagnosis applies, document "No active nutrition diagnosis identified" with brief justification.)

Nutrition Intervention

Pre-op Nutrition Targets: [Diet approach: balanced hypocaloric / meal replacements / liver-shrinking diet / other]. [Protein target: g/day or g/kg with calculation basis]. [Fluid target]. (For patients with diabetes on glucose-lowering medications, note coordination with the prescribing clinician before initiating very low-calorie diets.)

Behavior Change Plan:

• [Already doing / In progress / Not started / Not assessed] Regular meal pattern
• [Already doing / In progress / Not started / Not assessed] Protein-forward meals/snacks
• [Already doing / In progress / Not started / Not assessed] Elimination of sugar-sweetened beverages
• [Already doing / In progress / Not started / Not assessed] Carbonation cessation
• [Already doing / In progress / Not started / Not assessed] Caffeine reduction per program protocol
• [Already doing / In progress / Not started / Not assessed] Separate liquids from meals
• [Already doing / In progress / Not started / Not assessed] Slow eating and thorough chewing
• [Already doing / In progress / Not started / Not assessed] Food logging ([app / paper / other])
• [Already doing / In progress / Not started / Not assessed] Alcohol cessation
• [Already doing / In progress / Not started / Not assessed] Nicotine cessation ([plan/referral details])

Micronutrient Plan: [Baseline lab completion plan with timeline]. [Deficiency treatment if abnormalities exist, with prescriber coordination]. [Bariatric multivitamin/mineral protocol per program]. [Patient ability to obtain supplements and any assistance needed].

Post-op Diet Education: [Stages covered today: clear liquids / full-protein liquids / pureed / soft / regular bariatric pattern]. [Goals and key rules taught per stage]. [Teach-back demonstrated: topic and patient response]. (If education is incomplete, specify what was taught and what remains for future visits. Include lifelong vitamin/mineral commitment and follow-up expectations.)

Patient Goals: (2–4 specific, measurable, time-bound goals linked to identified diagnoses and readiness barriers.)

• [Goal 1 with target date]
• [Goal 2 with target date]
• [Goal 3 with target date] (Include only if applicable.)
• [Goal 4 with target date] (Include only if applicable.)

Referrals & Coordination: [Referrals placed: psychology / smoking cessation / endocrinology / social work / other]. [Communication plan with bariatric team]. [Safety instructions provided: red flags for persistent vomiting, dehydration signs, when/how to contact team].

Monitoring & Evaluation

• Next visit: [Date/interval]. Remaining pre-op visits: [Count/status].
• Monitoring targets: [Weight trend], [Food log adherence], [Beverage changes], [Protein intake], [Lab completion and repletion response], [Readiness milestones], [Other program-specific criteria].
• Nutrition clearance criteria: [Criteria and current status toward meeting each] (Include only if program uses formal clearance criteria.)

Clearance Status

Disposition: [Cleared / Cleared with conditions / Not yet cleared]

• Conditions/requirements outstanding: [Specific requirements for clearance] (Include only if not yet cleared or cleared with conditions.)
• Patient understanding confirmed: [Yes, via teach-back / Acknowledged verbally / Not confirmed]

(Do not document clearance if critical program requirements are incomplete.)