Sample Nutritional Assessment Form

A: PATIENTS' DETAILS Name/UID: _______________________Gender: ________ Age:______ Date of admission:_________

B: NUTRITIONAL HISTORY Diet regimen of patient: Diet supplements, if any: Food allergies: Age specific consideration: Religious or cultural food practices: Weight change (Yes/No): If yes whether intentional / unintentional

C: ANTHROPOMETRIC DETAILS Height (cms):________Weight (kgs): ______Ideal Body Weight:_______ Usual Body Weight:_______ BMI:___________ Condition: Very Obese / Obese / Overweight / Adequate / Underweight

D: MEDICAL DETAILS Diagnosis (or provisional diagnosis)_____________________________________________ Relevant lab findings: ________________________________________________________ Current medications:__________________________________________________________ Surgical details (if any):________________________________________________________ Any additional therapy: _______________________________________________________

E: PHYSICAL FINDINGS Skin/Muscle wasting Hydration status Edema Nausea Ascites Vomiting Diarrhoea Constipation Anorexia Early satiety Dysphagia Other

F: NUTRITIONAL NEEDS Current intake: Kcal/day________      Protein______(grams per kg)    Fluid ______(ml) Estimated nutritional needs: Kcal/day________      Protein______(grams per kg)    Fluid ______(ml)

G: NUTRITIONAL DIAGNOSIS AND INTERVENTION Problem 1: __________________________________Problem 2: _______________________________ Intervention 1: _______________________________ Goal 1: _________________________________ Intervention 2: _______________________________ Goal 2: __________________________________

H: MONITORING AND RE-ASSESSMENT PLAN:

F: SIGNATURE DETAILS Assessed by: ___________________________ Date of assessment: ____________________ Time of assessment: _____________________ Signature: ______________________________

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