NUTRITIONAL ASSESSMENT FORM
(Indoor Patient)
PERSONAL INFORMATION:
Date: _________________
PERSONAL
INFORMATION
PATIENT NAME AGE GENDER MARITAL
STATUS
HEIGHT WEIGHT SOCIO-ECONOMIC CONTACT
STATUS NUMBER
NO OF FAMILY MEMBERS
Members in family .
FAMILY MEDICAL HISTORY
______________________________________
ADDRESS
_______________________________________
OTHER HISTORY
Do you have children? Yes No
Are you pregnant? Yes No
ACTIVITY LEVEL
Low Moderate High
TYPE OF EXERCISE
Walk
Exercise
DURATION
_______________________________
STRESS LEVEL
Low Moderate High
SLEEPING CYCLE
Sleep time Wake time Sleeping hours
ANY MEDICAL CONDITION YOU HAVE DIAGNOSED WITH:
Hypertension Diabetes Constipation
Diarrhea Obesity Vomiting
Any Addiction? _______________
Current Medication: _____________
FLUID REQUIREMENT
Amount of water intake daily
Glasses/day .
TEMPERATURE OF WATER
Cold temperature Warm temperature Room temperature
YOUR DAILY FOOD INTAKE FROM FOOD GROUPS
Food items Quantity Types
Meat
Milk
Fruits
Vegetables
Fats
Cereals
CERTAIN FOODS THAT YOU NOT EAT?
---------------------------------------------------------------------------------------------------------------------
ANY FOOD ALLERGY OR INTOLERANCE
_________________________________________________
FAST FOOD FREQUENCY:
Daily ----------
Once a week -------
Twice a week -----------
Once a month --------
1. ANTHROPOMETERY:
“Refers to measurements of human individual “
MEASURMENTS:
1: BMI
Formula
BMI = wt. (kg) / ht (m) 2
Normal: 18-25
Underweight: <18
Overweight: 25-30
Obese: 35-40
2: BEE
Formula:
Male
= {66+ [(13.7* wt (kg)+ (5* ht (cm) ] - (6.8 * age (year) }
Female:
=655+ [(9.6 * wt (kg)] + [(1.7 * ht (cm) ]– [(4.7 * age (years) ]
3. Weight _____________
4: Height ____________
5: Waist circumference ___________
6: Hip circumference _______________
BMI: kg/m2
BEE: Kcal/day
TEE: Kcal/day
IBW: Kg
Fluid Requirements: glasses of water
2. PHYSICAL/CLINICAL ASSESSMENT
General Signs and ⮚ Loss of appetite Zinc
⮚ Pica-eating of non-nutritive
Symptoms substances
⮚ Loss of taste
⮚ Cold intolerance
Growth Failure ⮚ Failure to increase in
(Children) stature or weight and
⮚ excessive curvature of the
spine
Behavior ⮚ Easily fatigued, listless, Protein-energy malnutrition
apathetic, depressed,
nervous, irritable
⮚ Inability to concentrate,
complaints of insomnia
⮚ Poor work capacity
Skin ⮚ Dry, flaky, rough Essential fatty acids
⮚ Bed sore, poor wound
healing, edematous
⮚ Excessive bruising
⮚ Keratinization
⮚ Pinpoint, purplish
hemorrhagic spots
⮚ Symmetrical dermatitis
⮚ Itchy skin- pruritus
⮚ Carotenoderma- yellow
discoloration of skin
noticeable on the face and
trunk
Hair ⮚ Thin, sparse, dry,
lusterless, easily plucked
out
⮚ Hair loss
⮚ Change in pigments with
distinct bands
⮚ Dandruff, scalp hair loss
Face ⮚ Pale Iron
⮚ Scaling around nose
⮚ Swollen (edema)
Eyes ⮚ Pale, Dry and scaly at Iron
corners
⮚ Sensitive to light, itching
⮚ Increased vascularity
⮚ Night blindness, Bitot’s
spots, soft cornea,
exophthalmia
⮚ Conjunctival dryness
Lips ⮚ Fissuring at corners
⮚ Swollen, puffy
⮚ Cracking and peeling of
skin on the lips
Tongue ⮚ Pale Iron, Vitamin-B12
⮚ Swollen
⮚ Raw, scarlet red
⮚ Magenta red
⮚ Atrophy of papillae
⮚ Smooth, shiny and sore
⮚ Enlarged veins under the
tongue with micro-
hemorrhages
Mouth ⮚ Cracking at the corners of
the mouth
⮚ Recurrent mouth ulcers
⮚ Atrophic glossitis
Iron, Folate and Vitamin-B12
Teeth ⮚ Mottled enamel
⮚ Caries
Gums ⮚ Spongy, swollen, bleeding
Nails ⮚ Brittle, ridged, spoon
shaped, pale nail beds
Gastrointestinal ⮚ Diarrhea
⮚ Constipation
Dehydration, Fiber,
Magnesium, Potassium
Muscles ⮚ Wasted
⮚ Sore, painful
⮚ Weak
⮚ Loss of limb musculature
⮚ Muscle cramps
⮚ Calf muscle pains after
minimal exercise
⮚ Excessive calf muscle
tenderness
⮚ Walking with a waddling
gait
⮚ Difficulty getting up from
Magnesium, Potassium,
a low chair or climbing the
stairs or weakness of Sodium
shoulder muscles
⮚ Bowed legs
⮚ Twitching of facial
muscles when tapping on
the facial nerve in front of
the ear: Chvostek’s sign
Skeletal ⮚ Poor posture, delayed
closing of fontanelles
(infant), knock knees,
bowed legs, bending of
ribs, enlarged joints
⮚ Fleeting joint pain
2. Biochemical Assessment:
Laboratory Test Normal Ranges Patient’s Value
Serum Albumin (depends 3.3 – 5.0 g/dl
on method of analysis)
Senior: 3.2 – 4.4
Newborn: 2.9 – 5.5
To age 3: 3.8 – 5.4
3 – adult: 3.3 – 5.5
Alkaline phosphatase 19 – 74 IU/L
Newborn: 50 – 275
Infant: 100 – 330
Child: 90 – 230
Adult: 100 – 250
Blood Urea Nitrogen 4 – 22 mg/dl 28 mg/dl
(BUN)
Senior: 8 – 18
Paeds: 10 – 20
Newborn/infant: 8 – 28
Serum calcium 8.5 – 10.5 mg/dl
Chloride 100 – 106 mEq/L
Cholesterol 150 – 200 mg/dl
Children <200
Total CO2 23 – 30 mEq/L
Creatinine 0.7 – 1.5 mg/dl 1.05 mg/dl
Senior: 0.6 – 1.2
Newborn: 0.4 – 1.2
0 – 4 yr: 0.1 – 0.7
4 – 10 yr: 0.2 – 0.9
10 – 16 yr: 0.3 – 1.1
Ferritin 12 – 300 µg/L
<6 months: 25 – 200
6 months – 15 yr: 7 – 140
Globulin 2.3 – 3.5 g/dl
Glucose fasting levels 70 – 100 mg/dl Random B.G:-
<50 yr: 60 – 100 70 mg/dl
Senior: 55 – 125
Premature: 20 – 60
Newborn: 20 – 110
Child: 60 – 100
Hematocrit 39 – 51% 38.4%
36 – 15%
Senior: 30 – 54%
Newborn: 40 – 70%
Infant: 30 – 49%
Child: 30 – 42%
Adolescent: 34 – 44%
Hemoglobin 12 – 17 g/dl 14.0 g/dl
Senior: 10 – 17
Newborn: 14 – 24
Infant: 10 – 15
Child: 11 – 16
Iron 60 – 175 µg/dl
Newborn: 100 – 200
4 months – 2 yr: 40 – 100
Child: 85 – 150
Lymphocytes count (total 15,00 – 4,000 mm3 (closely 30%
% lymphocytes x WBC ) involved with immune
system)
Magnesium 1.4 – 2.3 mEq/L
Phosphorus 2.5 – 4.7 md/dl
Senior: 2.3 – 3.7
Newborn: 4 – 9
Infant: 4.6 – 6.7
Child: 4.0 – 6.0
Potassium 3.5 – 5.0 mEq/L
Protein, total 6 – 8.4 g/dl
Reticulocyte count 25,00 – 75,000 cells
RBC count (multiply 4.4 – 5.7 Total RBC’S:-
automatic counter values
x 1 million for total 1= ) 4.0 – 5.3 4.78
Senior: 3.0 – 5.0
(x 10/mm3)
(mil/mm3)
Sodium 136 – 145 mEq/L
Transthyretin (pre- 10 – 40 mg/dl
albumin or thyroxine-
binding pre-albumin)
TIBC estimated 250 – 450 µg/dl
transferring= (0.8 x
TIBC) – 43
Transferring saturation 20 – 50%
Triglycerides 40 – 150 mg/dl
Uric acid 4.0 – 8.5 mg/dl 4.2 mg/dl
2.7 – 7.3
Senior: 2.9 – 8.8
2.4 – 7.2
WBC count 4.5 – 10.6 thousand/mm3 6,900/Cumm
Zinc 85 – 120 µg/dl
3. DIETARY ASSESSMENT
● 24 Hour Recall
LUNCH
BREAKFAST
MORNING
SNACK
LUNCH
AFTERNOO
N SNACK
EVENING 1Pomegran 1 Fruit exchange
SNACK ate
DINNER
AFTER
DINNER
● Diet History
● Food Frequency Checklist
● SGA Form
24 HOUR RECALL
DIET HISTORY
FOOD FREQUENCY CHECKLIST
MEAT AND FISH
FOODS AND NEVER LESS 1-3 PER ONCE 2-4 5-6 ONCE 2-3 4-5 6+PER
AMOUNTS THAN A PER A PER PER DAY
ONCE/MONTH MONTH WEEK PER WEEK DAY DAY DAY
WEEK
BEEF
CHIKEN Yes
MUTTON Yes
FISH
LIVER
KIDNEY
CEREALS
PORRIDGE Yes
BREAD
PASTA
RICE Yes
BROWN
PIZZA Yes
CORNFLAKES
DAIRY PRODECT AND FATS
LOW FAT
YOGURT
FULL FAT Yes
YOGURT
EGG Yes
BUTTER
SALAD
CREAM
SWEETS AND SNACKS
SWEET BISCUITS Yes
CAKES
MILK PUDDING
ICE CREAM Yes
CHOCOLATES Yes
PEANUTS
FRUITS
BANANA Yes
APPLE Yes
PEAR
ORANGE
STRAWBERRY
MELON
DRY FRUITS Yes
OTHERS
VEGETABLES
CARROTS Yes
SPINACH Yes
CABBAGE Yes
POTATO
TOMATO Yes
CUCUMBER
PEAS Yes
OTHERS
SOUPS, SAUCES, AND SPREADS
VEGETABLE
SOUP
MEAT SOUP Yes
TOMATO
KETCHUP
JAM
PEANUT
BUTTER
OTHERS
Worksheet A
Subjective:.
Objective:
● Anxiety
● Neurosis
● Severe Ureteric Pain
● Low Fiber
● Low Iron
● Low vitamin B12
● Low Magnesium
● Low Potassium
● Low Folate
● Low Protein
● Low Zinc
Assessment:
Name:
Age:
Weight:
Height:
BMI: Kg/m2
BEE: Kcal/day
IBW: Kg
Fluid Requirement: glasses of water
Plan:
o High Fiber, medium proteins, low fat, low sodium, high potassium, medium calcium, high fluid
diet, high iron.
Worksheet B
Goals Plan Sources
Worksheet C
DIET CHART
Meal Name Timing Food items Quantity Form
Early Morning 6-7am
Breakfast 7-8am
Brunch 10-11am
Lunch 1-2pm
Snacks 4-5pm
Dinner 6-7pm
After Dinner 9-10pm
REQUIREMENTS
Total Calories Requirement-------------------------
Total Fluid Requirement----------------------------
RECOMMENDATIONS:
o Follow Up Notes_________________________________
Consultant Nutritionist Intern’s signature
