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Nutritional Assessment Form

This nutritional assessment form collects information about a patient's general health, diet history, meal timing, water intake, sleep patterns, physical activity, physical examination findings, biochemical lab results, metabolic stress level, and subjective global assessment (SGA) rating. It includes details like the patient's name, age, height, weight, BMI, ideal body weight, and diagnosis. Sections address the patient's appetite, gastrointestinal function, daily food group consumption, junk food intake, exercise habits, and signs of nutritional deficiencies. The form is used by a clinical nutritionist or dietitian to evaluate a patient's nutritional status.

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Laiba Javed
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3K views

Nutritional Assessment Form

This nutritional assessment form collects information about a patient's general health, diet history, meal timing, water intake, sleep patterns, physical activity, physical examination findings, biochemical lab results, metabolic stress level, and subjective global assessment (SGA) rating. It includes details like the patient's name, age, height, weight, BMI, ideal body weight, and diagnosis. Sections address the patient's appetite, gastrointestinal function, daily food group consumption, junk food intake, exercise habits, and signs of nutritional deficiencies. The form is used by a clinical nutritionist or dietitian to evaluate a patient's nutritional status.

Uploaded by

Laiba Javed
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NUTRITIONAL ASSESSMENT FORM

OUTDOOR PATIENTS

General Information
Date: Contact No.

Patient Name:

Age: Height: Weight: BMI:

IBW: Diagnosis:

GI Function
Appetite: Normal Suppressed Increased

Anorexia Nausea Diarrhea Constipation

Diet History
Daily Consumption of foods from each food group

Milk Products Bread and Cereals

Fruits Vegetables

Meat Fat

How often do you take Junk food?__________ Times / week:

Meal timing Do you skip meals? If yes, which one?

Breakfast time: ___________ Break Fast

Lunch time: ______________ Lunch

Dinner time: _____________ Dinner

Water Intake
Glasses / day:

Temperature: Cold Room temperature warm

Sleep-Wake Cycle
Sleep time: wake up time:
Exercise and walk
Duration: days/week

Type of Exercise:
Physical Examination:
Edema Present Absent

Muscle Wasting Present Absent

Ascites Present Absent

Skin Healthy Dry Scaly Patchy

Mouth Normal Sores Altered Taste Sensations

Tongue Deep red Rough Raw Swollen Smooth

Nails Pink nail beds Smooth Firm Spoon Shaped

Eyes Dry membranes Redness Red rimmed

Teeth Cavities Erupting abnormally Missing

Hair Dull Dry Thin Wire like Sparse

Biochemical Finding
Lipid profile iron

CBC Calcium

Renal Function test (RFT) Vitamin D

Liver Function test (LFT) Vitamin B12

Allergy /Drug interaction:

Metabolic Stress
Low Moderate High

SGA Rating
Well-nourished Moderately malnourished Severely malnourished

Nutritionist’s Notes: ___________________________________________________________

Clinical Nutritionist / Dietitian

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