Scored Patient-Generated Subjective Global Assessment Form (Pg-Sga)

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Patient ID Information
Scored Patient-Generated Subjective
Global Assessment (PG-SGA)
History (Boxes 1-4 are designed to be completed by the patient.)
1.
Weight (see Worksheet 1)
2. Food Intake: As compared to my normal intake, I
would rate my food intake during the past month as:
In Summary of my current and recent weight:
Unchanged
(0)
I currently weigh about _______ pounds
More than usual
(0)
I am about _______feet _________tall.
Less than usual
(1)
I am now taking:
One month ago I weighed about _______pounds
Normal food but less than normal amount (
1)
Little solid food (
Six month ago I weighed about ________pounds
2)
Only liquids (
3)
Only nutritional supplements (
3)
During the past two weeks my weight has:
Very little of anything (
4)
Decreased
Not Changed
Increased
(1)
(0)
(0)
Only tube feedings or only nutrition by
Vein (
Box 1
0)
Box 2
3. Symptoms: I have had the following problems that have kept
me from eating enough during the past two weeks (check all that
4.
Activities and Function: Over the past month, I
apply):
would generally rat my activity as:
No problems eating
Vomiting
Normal with no limitations
(0)
(3)
(0)
No appetite, just did not feel
Diarrhea
Not my normal self, but able to be up and about
(3)
like eating
Dry mouth
with fairly normal activities
(3)
(1)
(1)
Nausea
Smells bother me
Not feeling up to most things, but in bed or chair
(1)
(1)
Constipation
Feel full quickly
less than half the day
(1)
(1)
(2)
Mouth Sores
Fatigue
Able to do little activity and spend most of the
(2)
(1)
Things taste funny or have no taste
day in bed or chair
(1)
(3)
Problems swallowing
Pretty much bedridden, rarely out of bed
(2)
(3)
Pain; where?
____________________
(3)
Other*
____________________________________
(1)
Box 4
Additive Score of the Boxes 1-4
A
Box 3
**Examples: depression, money or dental problems
The remainder of this form will be completed by your doctor, nurse, or therapist. Thank you
Disease and its Relation to Nutritional Requirements
5.
(See Worksheet 2)
All relevant Diagnoses (specify)________________________________________________________________________
Primary disease stage (circle if know or appropriate) I
II
III
IV
Other _________________________________
Age _____________
6. Metabolic Demand (See Worksheet 3)
Numerical Score from Worksheet 2
B
7. Physical (See Worksheet 4)
Numerical Score from Worksheet 3
C
Numerical Score from Worksheet 4
D
Total PG-SGA Score
Global Assessment (See Worksheet 5)
(Total Numerical Score of A+B+C+D Above)
Well-nourished or anabolic (SGA-A)
(See Triage recommendations below)
Moderate or suspected malnutrition (SGA-B)
Severely Malnourished (SGA-C)
Clinician Signature__________________________RD RN PA MD DO Other___________Date_____________________________
Nutritional Triage Recommendations: Additive score is used to define specific nutritional interventions including patient and family
education, symptom management including pharmacologic intervention, and appropriate nutrient intervention: (food, nutritional
supplements, enteral, or parenteral triage). First line nutrition intervention includes optimal symptom management.
0 – 1
No intervention required at this time. Reassessment on routine and regular basis during treatment.
2 – 3
Patient and family education by dietician, nurse, or other clinician with pharmacologic intervention as indicated by symptom
Survey (Box 3) and laboratory values as appropriate
4 – 8
Requires intervention by dietician, in conjunction with nurse or physician as indicated by symptoms survey (Box 3)
≥9
Indicates a critical need for improved symptom management and/or nutrient intervention options.

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