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‘Wellness Evaluation Form Student cine wontnec (LAP Site/Faeulty: Tangle Nistvitin Therapy Please rate student performance on the following competencies using the rating system below: demonstrates entry level competence for dietitians, works independently 2= demonstrates entry level competence for dietitians, requires occasionally assistant ‘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 Counseling & Education Time Period date date 2] | Date Z] ju] date 2/32 ‘Student develops educational materials for : individualtarget group Si a 3 eS} Student prepares for counseingeducational session (Git plans, visuals, pt information spaered fom health care team) 3 3 e. ‘Student uses appropriate verbal and nonverbal ‘communication skills (student introduces self, shows 3 ‘2004 listening skills, uses open and close-ended {questions to explore patient responses) 3 3 Student knows and applis fundamentals of counseling for dietary change (correctly explains therapeutic tel plans appropate serving sizes, and demonstrate | ow ledge of nusrttonal supplement and food constituents) Ww W Student concludes counseling/eduationl session | (Gummary of information discussed planed behavior thangs reviewed folow-up and reterals discussed it | oe Te applieable) Comments: receptor date preceptor date doit de buf, MS ed, LDN : 3l2|15