Patient nutrition assessment form

A patient nutrition assessment form is a document that is used by healthcare professionals to assess the nutritional needs of their patients. The form can be used to assess the risk of malnutrition and to develop a plan to improve the patient's nutrition.

Time to complete

2 minutes

Eligibility

Patients who are suffering from any kind of nutritional deficiency can fill out the form. The form can also be filled out by parents or guardians of the patient.

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Questions for Patient nutrition assessment form

1.

What is your usual diet like?

The answer should be a text input.
2.

Do you have any allergies or food intolerances?

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

Do you have any chronic medical conditions that require a special diet?

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

Do you take any medications that could affect your appetite or nutrition?

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

Are you able to chew and swallow normally?

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

Do you have any difficulty preparing meals or eating out?

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

Do you have any trouble shopping for groceries or cooking meals?

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

Are you at a healthy weight?

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

Are you trying to lose, gain, or maintain your weight?

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

Do you feel like you are getting enough fruits, vegetables, and other healthy foods in your diet?

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

Do you eat fast food or processed foods often?

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

Do you drink alcohol, smoke cigarettes, or use other drugs?

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

Do you have any other concerns about your diet or nutrition? If yes, let us know.

The answer should be a text input.

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Here are some FAQs and additional information
on
Patient nutrition assessment form

What is a patient nutrition assessment form?

A patient nutrition assessment form is a document used by healthcare professionals to assess a patient's nutritional status. The answers to these questions help healthcare professionals determine if the patient is at risk for malnutrition or other nutrition-related health problems.

Why are patient nutrition assessment forms important?

By assessing a patient's nutritional status, healthcare professionals can develop a plan to improve the patient's overall health.

Who should use a patient nutrition assessment form?

A patient nutrition assessment form should be used by a healthcare professional, such as a registered dietitian, physician, or nurse.

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