NUTRITION AND DIETETICS SERVICES

NUTRITIONAL ASSESSMENT FORM

REHMAN MEDICAL INSTITUTE

PR No.

Patient Name Age Gender: M F

Consultant Location
ANTHROPOMETRIC MEASUREMENTS

Height: Ft./in Weight: kg BMI:

Improved Constant Decreased Actual Reported Estimated IBW:

Weight History/ Reason for Weight Change:

SUBJECTIVE GLOBAL ASSESSMENT
NUTRIENT INTAKE
1. No change; adequate
2. Inadequate; duration of adequate intake

Suboptimal soft diet Moderate Severe

3. Dietary Intake in past 2 weeks

Adequate Improved but No improvements/

not adequate inadequate
WEIGHT
1. Non fluid change past 6 months Weight: kg
5% loss or weight stability 5-10% loss without stability or increase 10% loss or ongoing
If above not known, has there been a subjective loss of weight during the past six months
None or mild Moderate Severe

2. Weight changes past 2 weeks Amount (if known) kg

Increased No change Decreased

SYMPTOMS (Experiencing symptoms affecting oral intake)
1. Pain on eating Anorexia Vomiting Nausea
Dysphagia Diarrhea Dental problems Feels full quickly
2. None Intermittent/mild/few Constant/severe/multiple
3. Symptoms in the past 2 weeks Resolution of symptoms Improving Decreased
FUNCTIONAL CAPACITY
1. No dysfunction Difficulty with Bed/chair ridden
2. Reduced capacity; duration of change ambulation/normal activities
3. Functional capacity in past 2 weeks
Improved No change Decreased
METABOLIC REQUIREMENT High metabolic requirement Yes No
PHYSICAL EXAMINATION POTENTIAL FOR
Loss of body fat No Mild/Moderate Severe Cachexia
Loss of muscle mass No Mild/Moderate Severe Sarcopenia
Presence of edema/ascites No Mild/Moderate Severe
SGA RATING A Well-nourished B Mildly/moderately malnourished C Severely malnourished
Normal Some progressive nutritional loss Evidence of wasting and
progressive symptoms

Dietician Name Signature Date Time

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RELEVENT BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES, MEDICATIONS

FOOD/ NUTRITION-RELATED HISTORY/VITAMIN/MINERAL/HERBAL SUPPLEMENT USE

Food allergies/intolerances:

Diet Order: Diet Received:

Food and Nutrient Intake/Meal Observation:

NUTRITION ASSESSMENT
Energy Requirement: Protein Requirement: Other:

Additional findings:

Skin integrity Chewing difficulty Shortness of breath Barden Scale Nutrition Score Fever

NUTRITION DIAGNOSIS

NUTRITION INTERVENTION
Nutrition prescription/Goals:

COORDINATION OF NUTRITION CARE

MONITORING AND EVALUATION

Follow-up Required: Yes No

Outcomes to be Monitored includes:

Dietician Name Signature Date Time

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