Kingdom Of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry Of Health ‫وزارة الصحة‬

Abu Arish General Hospital ‫مستشفى أبو عريش العـام‬
Dietary Department ‫قسم التغـذيـة‬

Form # 01 DT- 17.1.2 - 02

Nutritional screening

Name: File #: Adm. Date:

Age: Sex: □ M □ F Ward: RM/Bed #:
Diagnosis :

WT: HT: BMI:

Diet Order:

Screening Criteria : please check all that apply

□ BMI : [ 18 or 19 ] [ 15 – 17 ] [ Under 15 ]
□ pt on therapeutic diet
□ food allergy/intolerance
□ poor appetite
□ tube feeding
□ difficulty chewing or swallowing
□ nausea / vomiting / diarrhoea > 3 days
□ high risk OB / GYN [ hyperemesis , blood disorder ]
□ pregnant or lactating [ GDM, HTN, Renal..etc ]
□ paediatric growth < 3 % ile
□ age > 70 years
□ presence of chronic disease [ DM, HTN, Renal, Liver , Heart dis….]
□ increase metabolic requirement [ major surgery, burn, oncology …etc ]
□ GI problems
□ obesity
*pt. identified to be at nutritional risk based on meeting > 2 of criteria
□ pt at nutritional risk and need further assessment
□ p pt not at risk and no need for further assessment

Nurse : Sign : Date :

ALHAMZI