Sample Nutritional Screening Form

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: ______________________________

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