Assessment Date:

Name: __________________________________________________Unit/room/bed:___________________________

From___________________________________________________Dispo____________________________________

#:______________________________________________________________________________________________

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PMHx:__________________________________________________________________________________________

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Imaging:________________________________________________________________________________________

Labs:___________________________________________________________________________________________

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Rx:_____________________________________________________________________________________________

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I/O: ___________________________________________________________________________________________

1. Reason
LOS/ wound healing/ modified diet/ poor intake/
EN/PN/ CNST +/ post-op hip
2. How would you say is your appetite?
If poor, what do you think is the reason?
3. And before you came to hospital?
Food intake Diet in hosp:
a. How much have you been able to eat while in
hospital?
b. Food intake charted
c. Before hospital: Who does cooking/ purchasing
of food?
d. Place where you live provide any meals? Do you
use meal delivery services?
e. Diet Hx: Before coming to hospital walk me B:
through what you would eat on a typical day?
L:

S:

Snacks:
Drinks:
f. If protein is of concern: how often do you have
protein foods?
g. Did the amount of food you usually have Less or more
change?
h. Nutritional drinks like Ensure/ Boost?
Flavor?
Would you be interested in having it/
something you would want to try?
 i. Do you have dentures? Fitting well?
j. Difficulty chewing or swallowing?
k. Food allergies?
Anthropometric Measurements
Do you feel comfortable talking about your wt?
a. Usual body weight:
b. Weight history:

c. Height

Physical symptoms
a. BM; constipation/ diarrhea
Last BM
b. NVD
c. Edema/ fluid overload
d. O2
e. Wounds
Education
Adequate nutrition: eating enough/ nutritional
drinks/ adding items/ preferences/
Wound healing/ poor appetite
Protein intake
Vitamins/ minerals for wounds
Other

Interventions/ Goals