1. Soap Note 2
S- The patient is slowly beginning to curb her crave for sweets, but is still struggling to maintain
a healthy lifestyle, without rebounding to sugar. She reported that this week has been extra
stressful; mainly from her work, being a project manager. Even though she told me she would
start utilizing ‘Lose It,’ she has not begun to do so. Nonetheless, daily texts for the requests of
her daily meals have been fairly successful at keeping track of her meal track. She has begun
kick-boxing classes once again (30 minutes: 4 days this week).
O- Her weight is 141 pounds (started at 144 pounds)
A- There were no assessments taken this week
P- Patient has seen improvements this week, and is very motivated to continue with the
program. She believes that cutting the sugar count is making her feel very lazy. Patient has been
strong this week and has done 30 minutes of kick-boxing class for 4 days this week. She states
that this was mainly due to the added stress from work, and decided to vent the stress out at the
gym, rather than stress-eating. She has yet to get the ‘Lose It’ application, but I have been asking
for her daily meals every other night, so that I can obtain a fairly accurate depiction of what her
diet really consists of. The increment of one day to her kick-boxing routine has been a very good
addition to her life style. She does not know if she will keep up the 4 days of kick-boxing, and
may move it back down to 3 days. Overall, she needs to work on a more balanced diet, but it
seems that she is on a good start to reaching her goal. She states that she wants to keep her total
caloric intake at 1400 calories, at most.
REPORT
7/27/15 BREAKFAST: Honey Bunches of Oats + Fat Free Milk
(1.5)
240 cal.
White Peach (1) 51 cal.
LUNCH: Hard Taco (w/ Beef, Cheese, Lettuce) (2) 156 cal.
Dark Chocolate Covered Almonds (6 pc.) 132 cal.
DINNER: Chicken Breast (1) 124 cal.
Broccoli (0.5 cup) 15 cal.
Dark Chocolate Covered Almonds (10 pc.) 220 cal.
(insufficient) TOTAL: 938 calories
