Protocol Definition

Indication

Primary indication / target:

Inclusion / Exclusion

Who this protocol is for / not for:

Contraindications

Contraindications, medication interactions, allergy cautions:

Protocol Components

Components included:

Nutrition protocol

Supplement protocol

Botanical protocol

Lifestyle modification

Hydrotherapy

Movement Rx

Mind-body

Referral

Supplement Regimen

Regimen Name

Protocol regimen

Protocol Phase

Select Phase

Duration

New Supplement

Supplement Name

Form

Select

Strength Value

e.g. 200 mg

Dose Amount

Route

Select

Frequency

Select

Instructions

Adherence

Select

Start Date

yyyy-mm-dd

Stop Date

yyyy-mm-dd

Taper Details

Adverse Effects

+ Add Supplement

Hydrotherapy (if applicable)

Modality

Select Modality

Region / System

Select Region

Patient Position

Select Position

Setting

Select Setting

Course Phase

Select Phase

Course Duration

e.g. 4 weeks

optional

Temp Unit

C / F

Water Temperature

e.g. 38

primary water temp

Qualitative Temperature

Quality

Contrast Unit

C / F

Contrast Temperature

e.g. 16

optional - contrast pass

Contrast Quality

Quality

Duration Minutes

per cycle

Cycles

0-100

Total Duration

total session

Frequency

Select Frequency

Patient Instructions

Step-by-step instructions for the patient...

Notes

Dietary Pattern

Recall Window

Recall Method

Seven Day Recall

Recall Start

YYYY-MM-DD

Recall End

YYYY-MM-DD

Recall Window Days

days

Subjective ratings

Hunger

Rate how urgently your body is signaling a need for fuel before meals. 0 is a physical emergency (shaky/weak); 5 is neutral; 10 is constantly ravenous.

012345678910

Satiety

Rate the physical sensation of fullness after meals. 0 is empty/starving; 6 is comfortably satisfied; 10 is painfully full or sick.

012345678910

Cravings

Rate the intensity of your desire for specific foods. 0 is no specific desire; 5 is present but ignorable; 10 is an overwhelming 'must-have-now' urge.

012345678910

Post-Meal Energy

Rate your energy level 30–60 minutes after eating. 0 is a 'food coma' or extreme fatigue; 5 is stable/steady; 10 is highly energized.

012345678910

Food Group Intake Frequencies

Food Groups List Add Food Group

No food groups recorded.

Nutrient Aggregates

kcal

Protein (g)

Carbs (g)

Fat (g)

Fiber (g)

Added sugar (g)

Sodium (mg)

Nutrition Report Document

No nutrition report attached

Notes

Dietary patterns, dietary restrictions, nutritional compliance...

Handouts / Education

Education materials / patient instructions:

Monitoring

Normalized: —% Active Self Report

Capture

Diet Adherence Instrument

Search Adherence Instruments...

Capture Date

YYYY-MM-DD

Capture Method

Self Report

Score Override

Raw Score

0.0

Max Score

0.0

Normalized Score

0 - 100%

Band Label

Not provided

Notes

Patient diet adherence logs, barriers, food recall notes...

Symptoms to track:

Lab parameters:

Adverse effect monitoring:

Adherence metric:

Follow-Up

Outcome measure:

Follow-up interval:

Stop criteria:

Revision triggers:

Discharge criteria:

Plan and Follow-Up

Plan area	Details
Next visit
Orders & referrals
Patient instructions
Monitoring & safety

Protocol Definition

Indication

Inclusion / Exclusion

Contraindications

Protocol Components

Supplement Regimen

Supplement Regimen

Supplement Items

Hydrotherapy (if applicable)

Hydrotherapy Prescription

Modality

Temperature

Cycle & schedule

Instructions

Dietary Pattern

Dietary Pattern Snapshot

Handouts / Education

Monitoring

Diet Adherence Score

Follow-Up

Plan and Follow-Up

ND - Protocol Template (Nutrition / Supplement / Lifestyle)

Preview