Name:

Caraga Regional Hospital DIETARY SECTION Age: Gender:______ Case Number: Bed Num: ____________

Diagnosis: ________________________________Ward: _____________________

SCREENING CRITERIA FOR POTENTIAL NUTRITONAL RISK (check appropriate box) Food intake Burns Chronic pain Weight loss Sepsis Old age physical signs of malnutrition Multi Trauma Depression Radiation therapy Peritonitis Dentures Expected hosital stay > 2 weeks Fistulae Frequent diarrhea/ Malabsorption Cancer vomiting On-tube feeding Anorexia SUBJECTIVE DATA OBJECTIVE DATA Food Intake No change Height(cm): ____________Weight(kg): __________ Mostly liquids Usual Weight(kg): _______BMI: ________________ Sub-optimal Weight Change: ______% over ______months/week Starvation % IBW: ____________________________ Poor intake prior to Significant Labs: admission Albumin Total Lym Count Functional Capacity In bed HCT HGB Ambulatory Others: Needs assistance Chewing/Swallowing Difficulties: _________ Constipation: ____________ Diarrhea: ___________ Medications: _________________________________ Food Allergies: Present Diet Px: SCORING OF NUTRITIONAL RISK RELATED RISK FACTORS Screening criteria for potential nutritional risk Mechanical/Digestive Problem (1) one check or more (1-2 points) Depressed Albumin (1 point) <85%or >130% Ideal Body Weight (1 point) Significant Lab Result (1 point) Unintentional Weight Loss ______% over ____ Other: ________________________________ months or weeks (2 points) Total Points: A nutrition risk factor with the following total score indicates: 1 Low Risk 2-3 moderate >3 High Risk Nutritional Status: Normal Moderate Severe Malnutrtion DIETITIAN'S RECOMMENDATION Shift diet to ______________________ Monitor Caloric Intake Nutrition education Total caloric Reqt: Request for Laboratory Data Total Protein Reqt Other:

Name & Signature of Nutritionist - Dietitian

License Number

Date