Hospital Patient Malnutrition Survey

The Hospital Patient Malnutrition Survey is a self-administered questionnaire that assesses a patient's risk of malnutrition. T Patients are asked to rate their overall health, energy levels, and ability to perform daily activities. They are also asked about their weight loss, appetite, and food intake.

Time to complete

3 minutes

Eligibility

Patients who are 18 years of age or older and are admitted to the hospital for at least 24 hours are eligible to participate in the survey.

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Questions for Hospital Patient Malnutrition Survey

1.

Have you ever been diagnosed with malnutrition?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
2.

Are you currently at risk for malnutrition?

The answer should be a text input.
3.

Do you have any medical conditions that put you at risk for malnutrition?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
4.

Do you have difficulty eating or swallowing?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
5.

Do you have any food allergies or intolerances?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
6.

Do you have any digestive problems?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
7.

Do you have any medical conditions that cause you to urinate frequently?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
8.

Do you have any medical conditions that cause you to have loose stools or diarrhea?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
9.

Do you have any medical conditions that cause you to vomit frequently?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
10.

Do you have any medical conditions that cause you to have a decreased appetite?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
11.

Do you have any medical conditions that cause you to have difficulty digesting fat?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
12.

Do you have any medical conditions that cause you to have difficulty digesting protein?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
13.

Do you have any medical conditions that cause you to have difficulty digesting carbohydrates?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
14.

Do you have any medical conditions that cause you to have a decreased absorption of nutrients?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
15.

Are you on any medications that put you at risk for malnutrition?

The answer should be a text input.
16.

Are you pregnant or breastfeeding?

The answer should be a text input.
17.

Are you underweight?

The answer should be a text input.
18.

Have you lost weight recently without trying?

The answer should be a text input.
19.

Do you have a poor appetite?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
20.

Do you eat fewer than three meals per day?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
21.

Do you eat mostly unhealthy foods?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure

Similar Ideas

  • Malnutrition Screening Tool
  • Malnutrition Universal Screening Tool
  • Patient
  • Generated Subjective Global Assessment
  • Geriatric Nutritional Risk Index
  • Mini Nutritional Assessment
  • Nutritional Risk Screening 2002

Here are some FAQs and additional information
on
Hospital Patient Malnutrition Survey

What is the purpose of this survey?

The purpose of this survey is to help assess the prevalence of malnutrition among hospital patients and to identify any risk factors that may be associated with it.

How will my information be used?

Your information will be used to help assess the prevalence of malnutrition among hospital patients and to identify any risk factors that may be associated with it. All information collected will be kept confidential.

What are the risks and benefits of participating in this survey?

The risks of participating in this survey are minimal. You may experience some discomfort if you are asked to provide information about sensitive topics, such as your eating habits or your weight. However, the benefits of participating in this survey include helping to improve the quality of care for hospital patients.

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