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MEDICINE AND SURGERY NUTRITION ASSESSMENT CHECKLIST
(This checklist is to prompt you during patient interviews. You are required to fully complete the checklist, and include the nutrition information on your medicine or surgery write-up that you feel is
relevant. Bring one copy of the checklist, write-up and the cover sheet when you present to your
nutrition preceptor.)
Present Illness:
Medical History:
Is the patient taking any vitamins, minerals or other food or nutritional supplements?
Yes No if yes, which ones?_____________________________________
Does the patient have any food allergies? Yes No
If yes, to what?
_______________________________________________________
Social History:
Does the patient drink alcohol? Yes No
Type Quantity Frequency Duration
Beer__________________________________
Wine__________________________________
Liquor_________________________________
Was the patient following any special diet prior to admission ? Yes / No
Low salt Low fat, low cholesterol Low sugar Other
Is the patient compliant with this special diet?
Yes, always Sometimes Not usually Uncertain
How many meals does the patient eat during the day?______ How many snacks?______
If the patient has insulin dependent diabetes, what time are meals eaten? Time of insulin injection?___________________________________________________________
If the patient has diabetes, does he/she self-monitor blood glucose levels?
Yes / No If yes, when?____________________________________
If the patient is obese, do they have a history of dieting? Yes/No
If yes, explain_______________________________________________
Do they have an interest in dieting? Yes / No
Review of Systems:
General:__________________________________________________________
Skin:____________________________Hair:____________Nails:____________
Head:____________________________________________________________
Eyes: ____________________________________________________________
Mouth: ___________________________________________________________
GI/Abdomen: ______________________________________________________
Cardiac: __________________________________________________________
Extremities: _______________________________________________________
Neurological: ______________________________________________________
Musculoskeletal: ____________________________________________________
Physical Examination:
General: ___________________________________________________________
Skin:_____________________Hair:_________________Nails:________________
Head: _____________________________________________________________
Eyes: _____________________________________________________________
Mouth: ____________________________________________________________
GI/Abdomen: _______________________________________________________
Cardiac: ___________________________________________________________
Extremities: _________________________________________________________
Neurological: ________________________________________________________
Musculoskeletal: _____________________________________________________
Height: _________ _(feet and inches)__ __Current Weight: (pounds)
Usual weight:________________(pounds) Ideal weight (estimated):_________________ (pounds)
% Ideal weight (calculated):___________ % Usual weight (calculated):_____________
Interpretation of % IBW:______________________________________________________
Interpretation of % UBW:
____________________________________________________________
% Weight Change (calculated):________________________________________________________
Evaluation of % Weight Change:_________________________________________________
Laboratory Evaluation:
Serum Albumin (normal = 3.5 - 5.8 mg/dl)___________________
Significance:______________________________________________________
Serum Prealbumin (normal = 16.6 - 43.1 mg/dl)___________________
Significance: ______________________________________________________
Serum Transferrin (normal = 200 - 400 mg/dl) ) ___________________
Significance: ______________________________________________________
Serum Glucose (normal = 70 - 1 10 mg/dl)) ____________________
Significance: ______________________________________________________
Hematocrit (female normal = 36 - 46%), (male normal = 40 - 52%)
Hemoglobin (female normal = 11.8 - 15.5 mg/dl), (male normal = 13.5 - 17.5 mg/dl)
MCV/MCHC (check computer for normal values)
Significance: ______________________________________________________
Serum Cholesterol (normal < 200 mg/dl)
Significance: ______________________________________________________
Serum Triglycerides (normal < 150 mg/dl))
Significance: ______________________________________________________
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