Patient label MATERNAL NUTRITION SCREENING FORM

Height:__________ Weight:__________________BMI:__________
Tick conditions that apply
Nutritional Status:  Adequate  Underweight  Overweight
S.N Questions First trimester Second Third trimester
o Yes No trimester Yes No
Yes No
1 During pregnancy, how much weight did the      
patient gain?
 10 kg <10 kg >10 kg
2 Experiencing discomfort?      
Mark all that apply:
 Nausea  Vomiting
 Diarrhoea  Constipation Oedema
3 Do any of the following apply to the patient?
Mark all that apply:
 Anaemia      
 Diabetes      
 Type 1  Type 2  Gestational      
 Abnormal blood pressure      
4 Is the patient currently taking any of the      
following supplements?
(Iron, folic acid, prenatal vitamins/minerals)
5 Is the patient appetite been good since      
becoming pregnant?
6 Do the patients have any food allergies?      
7 Does the patient skip meals?      
8 Is the patient following any special diet?      
9 Diet counselling was done to the patient.      

Seen by dietician
Name:
Signature:
Date & Time:
 FOODS DURING PREGNANCY
 The pregnant/lactating woman should eat a wide variety of foods to make sure that her own nutritional
needs as well as those of her growing foetus are met.
 There is no particular need to modify the usual dietary pattern. However, the quantity and frequency of
usage of the different foods should be increased.
 She can derive maximum amount of energy (about 60%) from rice, wheat and millets. Cooking oil is a
concentrated source of both energy and polyunsaturated fatty acids. Good quality protein is derived
from milk, fish, meat, poultry and eggs. However, a proper combination of cereals, pulses and nuts
also provides adequate proteins.
 Mineral and vitamin requirements are met by consuming a variety of seasonal vegetables particularly
green leafy vegetables, milk and fresh fruits. Bioavailability of iron can be improved by using
fermented and sprouted grams and foods rich in vitamin C such as citrus fruits. Milk is the best source
of biologically available calcium.
 Though it is possible to meet the requirements for most of the nutrients through a balanced diet,
pregnant/lactating women are advised to take daily supplements of iron, folic acid, vitamin B and
calcium (as per doctors’ advice).
 Adequate intake of a nutritious diet is reflected in optimal weight gain during pregnancy (10 kg) by the
expectant woman. She should choose foods rich in fibre (around 25 g/1000 kcal) like whole grain
cereals, pulses and vegetables, to avoid constipation
 She should take plenty of fluids including 8-12 glasses of water per day.
 Salt intake should not be restricted even to prevent pregnancy-induced hypertension and
 pre-eclampsia.
 Excess intake of beverages containing caffeine like coffee and tea adversely affect foetal growth and
hence, should be avoided.
 She requires enough physical exercise with adequate rest for 2-3 hours during the day.
 Smoking and tobacco chewing and consumption of alcohol should be avoided.
 Wrong food beliefs and taboos should be discouraged.
 The most important food safety problem is microbial food borne illness and its prevention during
pregnancy is one of the important public health measures. Avoiding contaminated foods is important
protective measure against food borne illness.

(Revised from NIN recommendations-2022)