Sample Nutritional Screening Form

PATIENTS' DETAILS

Name/UID: _______________________Gender: ________ Age:______ Date of admission:_________

Weight (kgs):_______________ Height (Cms):_____________ BMI: ___________________________

Diabetic: Yes/No Hypertensive: Yes/No Any other clinical condition: ______________

OBSERVATION

1. Appearance of underweight? Severe / Moderate / No

2. Decrease in food intake? Severe decrease / Moderate decrease / No change

3. Pale appearance? Very much / Moderate / Mild / None

4. Weakness? Yes / No

5. Muscle wasting? Yes / No

6. Any other physical finding related to nutritional problem?

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FINDINGS AND ADVICE

Nutrional problem observed (if any): _________________________________________________
Detailed Nutritional assessment required: Yes / No (Reason: ______________________________)
Any nutritional advice given: ________________________________________________________

SIGNATURE DETAILS

Screened by: ___________________________ Date of screening: _______________________

Time of screening: _______________________ Signature: ______________________________