Subjective Global Assessment Form MEDICAL HISTORY Part re L. Prasoue owe 0, 08 , 2022 NUTRICNT INTAKE 1. Onochargs: seat 2. aogier of adequate tk startin eke det Fults orery alm supiorerts COM, clear for stanton 3. Nutyjent tak in past 2 weekar eect. Cinpoed not doccte {No mproment or hacen —_ WEIGHT Usuat weight 43 current weignt GO 1. Non ud weight change past 6 months Vt xa fe) Sh 125% ss or wel aby (15-10% bss vate sabtazton or rcease {1 >10% xn an ong 1 abe ratlronn hs there been ikecve oes of weg ug the past eka? fore cris CIM pace 2. Weight change past 2 weeks! Ano tioonn) SEG Z Oincraased DNo change (Cthecreased SYMPTOMS xperencing symptoms attecting oral intake) 1. Drancneang Caro Deming Nason erage Darn Cooraipctlons — Feds hank Oconstemion 2. cere Cirtenitarmiciew ——C1Consanveevrmtcle 8. Symptoms inthe past 2 weeks Oresoutenctsyrpions — Cimeraing §——aKioctange or wersened : FUNCTIONAL CAPACITY (aiigve onc progressive loss of function) 1. decustecten 2. Redcar capacity, aan of change tty ath ousterromal Diaaaenarso 4 Funetional Capacity inthe past 2 weeks” Dirneroed No canon Doecrease METABOLIC REQUIREMENT Hen metabate raaurament whe yes PHYSICAL EXAMINATION Loss of vody at Bo OmisMoseraie Osevere Leas of msde mass mo OMisnoces Osevrere Prosence of edona/scies Dr Cmianvooee Osenee SGA RATING BK wengioes CB thymotoam armas «Cena Noel Siroresenste nora s BER eqs omotons CONTRIBUTING FACTOR CICACHERA ft osc wasing cto saa and errand) CLSARCOPENIA rosin rus rass a sen “see page din) cng ‘See page 2 SGA Rating fr more description. tin ge April 2017 Tas Force” | sur la malntetioe«.» Subjective Global Assessment Guidance For Body Composition SUBCUTANEOUS FAT Undir the ee Slahty rulcing ea 7 | Scmenhat naews look Sichiy | Halowed look, dacression. dark z dak orcs, ‘robs. "Wicens| Large apace between thas , | Some depth to tat issue, but not | Very ite space betwosn froers, . “7 | STs Lcea ingen | OY rea toch ‘Rios, ower back, sides of burk | _Chostls fl, nos do nal snow, | Fibs ob,jous, bu indentations are| _wndertaton batwoen ros very Sipttono erase oe | reat. ba Gee coment | covaue. to Geet very Bomar est Bromine MUSCLE WASTING _| Miid?Moderate | Temple Weldetnedmuscs 7 ‘Sight denresscn Hollowing, Gepression| Cave Nolan males; may be | Some promusion; may notbe al | Protuding/prominent bane | wabe bulnot pomnetin# the may along females ‘Shoulder Rounded 7 | _Nosquae took ‘Square look, Bones prominent | proces rey pronase Sig ty ‘Scapularbs Bores nol romnest no 7 | Mid depressions orboe may | Bones prominent sirifcant ‘Sgrifcant Geprassions Show sighynot all areas pressions (Quadticeps Wat dered 77 | Oaesscrvatony medal Prgmbertinee, Gace Trlorossocus musale betwoan tram ard fovtrger (back oF ana) Sort deprossad fora None Pring ecena cleasmites/ | Prin baerdinees, sce / | shinai roos.oscsblesaval | acora {Bock ray aso eaenat bos aan Pov oererezed auora 7scies “Ame Pron! fay ony be reser on negra) ‘A Woll nourished no decease in ood/utntintk< 8% wages no/inmal smrpionsafectng onda: ro den func: no dlc fat ormuscie mass OR an cal win overacy SGA oC bul win recor aerate 100 rave, notid wagh gan servcart Tecert trprovernaré mn syirptems allewing adequete ord nak, sgnifcanl rece irpyovemert in (uncon; arc Conic defi in fat ang muscle mess but wih recent clrical improvement in function B - Mildly/moderately malnourished cette decrease " \ood/nuivent intake; 5% - 10% weight loss without stabiizaton or gan; mid/some syrpiors affacing toed iniaxe, moderate funcional Cefext or recent dataricaton: mic/mederaie loss of fat and/or muscle mass OR “2 indvvcual meeting citer for SGA C but wih improvement (out not adequate) of Or intake, recent stabiization of weight, dacrease in symptoms fflectne oral ntzk®, and stablzaton of functional status. - Severely mainourehed cow dct foodrtiont alo; > 10% weir ls which song sgrcet symptoms ats fod inet PSG Sows tachenal Gack ON wo ecare Celeron Noo Sore 8 ale mabe ons, Cachexla - there is'an underlying predisposing disorder (ag. malignancy) and there is evidence of reduced muscle and fat and no or knitad improveriont wth spinal muon weak, te is coneiston wi cacnax, ‘Sarcopenia- therais an underhing csorder (0.9, agin) ard there's evdance of reduced muscle and strength and no er lirted improvernent with optimal rutrant nike, usta | sora cade Take | le maior “nh lay promis andne ad hallow here aging and may ot ret mation. W) mtn wept