The dietitian’s client record: dietary history, measurements and plans in one place

The first session lasts an hour and fills three pages of notes. By the third month, when the client says “I’ve stopped losing weight”, the question is simple: what has changed since then? If the answers are scattered across a notebook, a spreadsheet and messages, the session is spent searching instead of solving.

The client record is the tool that makes every session a continuation of the last. These are the parts worth having.

History taking: written once, read every time

• Medical history as the client reports it: conditions, medication, supplements, recent blood tests.
• Allergies and intolerances — a separate, prominent field, not a line lost in the notes.
• Eating habits: meal times, snacking, eating out, alcohol, likes and dislikes.
• Lifestyle: work, sleep, exercise, who does the cooking at home.
• The goal in the client’s own words — “to fit into my wedding suit in June” says more than “-8 kg”.

Measurements: per session, with a date

Weight, waist and hip circumference, body composition if you measure it. What matters isn’t which measurements you keep but keeping the same ones, the same way, at every visit. Only then does the series of numbers become a progress curve — and only then can you see that the waist dropped two centimetres in the month the scales “got stuck”.

More on how to read that curve in the article on tracking progress beyond the scales.

Meal plans: every version, not just the latest

When you change the plan, the old one isn’t thrown away. It’s attached to the record with its date, so at the follow-up you know which plan corresponds to which period of measurements. That way you can see what worked, what didn’t, and why you made the change.

Session notes

• How the week went in the client’s words — difficulties, celebrations, trips.
• What you agreed to change before next time.
• The date of the next appointment, so nobody “drops off” after a difficult patch.

Who sees the record

Medical history and test results are health data — a special category under GDPR. They need encrypted storage and role-based permissions: reception books appointments and sees package balances without opening the history. Clients have the right to request a copy of their file, so exporting it needs to be easy.

In NutriPro, every client has a record with dietary history, measurements per session, dated plans and the test results they bring — with voice notes so you don’t have to write while the client is talking.

Conclusion

History once, measurements every time, dated plans and a couple of lines of notes at the end of each session. That’s enough for clients to feel you remember them — and for you to see what really works.