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Wellness Evaluation Form Student: Sexy Wagener ¢ LP Site/Faculty: Tande Munition Therapy Pease rate student performance on the following competencies using the rating system below: 3 = demonstrates entry level competence for dietitians, works independently 2-= demonstrates entry level competence for dietitians, requires occasionally assistant 1 = working toward entry level competence for dietitians, requires regular assistance (0 = does not demonstrate entry level competence for dietitians, requires routine assistance and needs to improve knowledge base. NO =Not Observed, NA = Not Applicable trition Screening & Assessment Time Period date 2/2 | date 7/4 [date 2[iu | date 2/7 + : Student performs screening of clients for nutrition and health status and documents results oS S 3 we Ww Student efficiently locates pertinent information 3 3 from client's records 3 a 2 Student includes all nutritionally relevant information in the nutritional assessment. < = ow W ww Student interviews client for nutrition related data . on activity level, and for cultural, economic, and ey 2 demographic factors using appropriate 3 3 S interviewing techniques. ‘Student understands and evaluates anthropometric 3 data relevant to clients needs. Comments: 1_onla 3. preceptor date preceptor date 2. 4 preceptor : date preceptor a date MS, 2D, DN 3/2)