Nutrition Assessment Template
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1
2Georgia Department of Behavioral Health and Developmental Disabilities
XXX Hospital
The individual’s Identification
Address
NUTRITION ASSESSMENT
NAME: __________________________________________
ADMISSION DATE: ________________________________
ID#: ____________________________________________
REASON FOR ASSESSMENT:
Annual
Update
Admission/Initial
Referral or request: _____________________________________________________________________
INDIVIDUAL’S NUTRITION GOALS, CONCERNS, AND PRIORITIES: _______________________________
________________________________________________________________________________________
PERTINENT DIAGNOSIS/HISTORY: _________________________________________________________
________________________________________________________________________________________
CULTURAL AND/OR RELIGIOUS DIETARY PRACTICE: _________________________________________
ACTIVITY LEVEL:
Sedentary
Active
Exercise (activity and frequency): _______________________
________________________________________________________________________________________
OBJECTIVE FINDINGS:
Diet Order: ______________________________________________________________________________
Snacks and/or supplements: ______________________________________________________________
Liquid specifications:
Regular
Nectar
Honey
Pudding
Fluid restrictions: ________________
Labs: Date(s):
____________________________________________________________________________________
Glucose
Phos
Albumin
_______
_______
_______
↑
↓
↑
↓
↑
↓
n/a
WNL
n/a
WNL
n/a
WNL
BUN
Chol
Hb
_______
_______
_______
↑
↓
↑
↓
↑
↓
n/a
WNL
n/a
WNL
n/a
WNL
Creat
Trig
Hct
_______
_______
_______
↑
↓
↑
↓
↑
↓
n/a
WNL
n/a
WNL
n/a
WNL
Na+
HDL
Amm
_______
_______
_______
↑
↓
↑
↓
↑
↓
n/a
WNL
n/a
WNL
n/a
WNL
K+
LDL
HbA1C:
_______
_______
_______
↑
↓
↑
↓
↑
↓
n/a
WNL
n/a
WNL
n/a
WNL
Ca
TP
Other:
_______
_______
_______
↑
↓
↑
↓
↑
↓
n/a
WNL
n/a
WNL
n/a
WNL
Age: ____ Ht: ____________ Wt: _____________#/kg Ideal Body Weight: _________________________
BMI: __________
Underweight
Normal
Overweight
Obese
Extreme Obesity
Adjusted wt: _______
N/A Significant weight changes: _________________________
N/A
Food allergy and/or intolerance: ___________________________________________________________
Food Preference(s):_ _____________________________________________________________________
Physical appearance and/or body composition: ______________________________________________
Cholesterol/HDL ratio: _________________________
Blood Glucose level patterns:
Within target level
Atypical: ___________________________________
_______________________________________________________________________________________
Potential food/drug interaction: ____________________________________________________________
________________________________________________________________________________________
Meal intake:
Documented
Observed
> 75%
50-75%
25-50%
< 25%
Fluctuates:
________________________________________________________________________________________
RDI: Kilocalories: _________________________________ Protein:__________________________________
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