<p>Community College of Philadelphia 24-Hour Recall Form Dental Hygiene Clinic</p><p>Patient Name Date </p><p>Session Student Name </p><p>List all of the foods and beverages that the client consumed in the last 24 hours.</p><p>TIME PLACE FOOD AMOUNT PREPARATION Community College of Philadelphia Case Notes Dental Hygiene Clinic</p><p>Patient Name ______Student______Date: ______</p><p>VISIT I (Assessment )</p><p>Rationale for Patient Selection:</p><p>Admission Summary:</p><p>Personal and Social Information:</p><p>Diet History and Current Dietary Practices:</p><p>Visit II (Education)</p><p>Pertinent Information from Diet Analysis:</p><p>Principles Taught:</p><p>Visit III (Goals and Follow-up)</p><p>Additional Information/Modification of Plan: Comparison/Improvements </p><p>Grady/nutdentassessment</p><p>Community College of Philadelphia Nutrition Education Summary Sheet Dental Hygiene Clinic</p><p>Patient Name Student Name </p><p>Folder Number </p><p>Visit I Visit II (education only) Visit III</p><p>Date ______Age ______Height ______Weight ______DMF ______Plaque Index ______</p><p>Food Groups (Total Servings) Bread and Cereal ______Vegetable ______Fruit ______Milk ______Meat ______Fats, Oils, and Sweets ______</p><p>Sucrose Exposures ______Non-retentive ______Retentive ______</p><p>Vitamin/Mineral Supplements ______Name Type ______</p><p>Water Fluoridated ______Non-Fluoridated ______</p><p>Oral Hygiene (Times day and when) Brushing ______Flossing ______Swishing ______Community College of Philadelphia Dental Hygiene Clinic</p><p>EDUCATIONAL GOALS AND PLAN</p><p>Please address your objectives, goals and any usage of visual aids during educational visits.</p><p>Gradydentassessment Community College of Philadelphia Diet and Oral Hygiene Relationship Dental Hygiene Clinic</p><p>A. The Caries Process</p><p>FOOD + BACTERIA = ACID</p><p>ACID + SUSCEPTTIBLE TOOTH = DECAY</p><p>B. Oral Hygiene Care</p><p>Objective: To decrease the amount of food in contact with the tooth and the numbers of bacteria through Brushing, Flossing, Swishing.</p><p>Times/Day When BRUSHING FLOSSING SWISHING</p><p>C. Fluoride</p><p>To Strengthen Teeth a. Fluoride in water b. Topical application of fluoride c. Fluoridated dentifrice WATER ...... Fluoridated Non-fluoridated Amount / day DENTIFRICE ...... Brand Fluoridated </p><p>D. Decrease Added Sugar Consumption</p><p> a. From 24 hour recall, list food and drinks sweetened with added sugar – Please Circle in red. b. Differences between retentive vs. non-retentive foods sweetened with added sugar.</p><p>Sucrose Foods with meals Between meals Foods with Added Sugar Retentive Non-retentive Total added sugar Exposures + =</p><p>Potential Acid Production Total Added Sugar Exposures X 20 minutes of AVERAGE ACID PRODUCTION 20 = MINUTES Community College of Philadelphia Diet and Oral Hygiene Dental Hygiene Clinic Modification Prescription</p><p>TO AID IN DENTAL CARIES PREVENTION AND PLAQUE CONTROL</p><p>Name Date </p><p>My diet can be improved by including these foods from the Food Guide Pyramid. Name of foods: When:</p><p>My diet can be improved by adding these hard textured foods requiring chewing: Name of foods: When:</p><p>My diet can be improved by: Decreasing these foods AND Substituting these foods which sweetened with added do not contain added sugar: sugar:</p><p>I will reduce the number of between-meal snacks to times each day.</p><p>I will brush my teeth after the following meals and snacks:</p><p>I will swish my mouth after the following meals and snacks:</p><p>I will floss my teeth </p><p>Next appointment: Patient Signature </p><p>Student Signature </p><p>TG/rm/DAH/Grady/Dental Nutrit Assessmnt/S Drive Community College of Philadelphia Food Guide Pyramid Analysis Dental Hygiene Clinic</p><p>Patient’s Name ______</p><p>Date ______Student’s Name ______</p><p>Food Group Soft/Liquid Hard/Solid Total Recommended Difference Serving Sizes Textured Textured Servings (+,-, ok) Grain (hard crusts) 6-11 1 slice bread ¾ c. – 1 c. dry cereal = 1 oz. Ready-to-eat ½ c. cooked cereal ½ c. pasta/rice/grits 3-4 plain crackers 1 pancake/waffle ½ bagel, hamburger roll ½ English muffin 1 pita Vegetables (crunchy raw 3-5 1 small potato vegs.) ½ c. cooked vegetable 1 c. green leafy vegetable 10 French fries* Fruits (crunchy raw 2-4 ¾ c. fruit juice fruits) 1 medium piece fruit ¼ c. raisins/dried fruit Milk 2-3 1 c. Milk/yogurt/pudding 1 ½ oz natural cheese* 2 oz process cheese* 1 ½ c. ice cream*/ice milk Meat, Poultry, Dry 2-3 Beans 2 ½ - 3 oz. Lean meat/poultry, fish 2 wings, 1 drumstick, thigh 2 hot dogs 2 T peanut butter, 1 egg,* or ½ c. cooked, dry peas, beans = 1 ounce meat Other Foods Butter, margarine, mayonnaise, oils, candy cookies, cake, pie, rich desserts, chips & other salty snacks, jello, fruit drinks, ades, punch, soda *Foods high in fat.</p>