Center for Human Nutrition

Medical Nutrition Syllabus

Guide to Healthy Diet and Lifestyle

Exercise Guidelines

Managing Obesity

Exercise Prescription

Medicine and Surgery Nutrition Assessment Checklist

Pediatric Nutrition Assessment Checklist

Adolescent Nutrition Assessment Checklist
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: ______________________________________________________