PATIENTS' DETAILS
Name/UID: _______________________Gender:
________ Age:______ Date of admission:_________
Weight (kgs):_______________
Height (Cms):_____________ BMI: ___________________________
Diabetic: Yes/No Hypertensive: Yes/No Any other clinical condition:
______________
|
OBSERVATION
1. Appearance of underweight? Severe / Moderate / No 2. Decrease in food intake? Severe decrease / Moderate decrease / No change 3. Pale appearance? Very much / Moderate / Mild / None 4. Weakness? Yes / No 5. Muscle wasting? Yes / No 6. Any other physical finding related to nutritional problem?
_________________________________
_________________________________
_________________________________
|
FINDINGS AND ADVICE
Nutrional problem observed (if any):
_________________________________________________
Detailed Nutritional assessment required: Yes / No (Reason:
______________________________)
Any nutritional advice given: ________________________________________________________
|
SIGNATURE DETAILS
Screened by: ___________________________ Date of screening: _______________________
Time of screening: _______________________ Signature:
______________________________
|
Other forms
