Nutritional Assessment Form

The Nutritional Assessment Form is a clinical tool designed to systematically evaluate a patient's nutritional status, dietary intake patterns, and risk for malnutrition or nutrient deficiencies. It captures anthropometric measurements including weight, height, and BMI calculation, along with detailed dietary recall information covering meal frequency, food group consumption, and special dietary restrictions or preferences.

This form includes validated screening questions adapted from established nutritional risk tools to identify patients who may benefit from dietitian referral or nutritional intervention. It documents relevant medical conditions affecting nutrition, current supplement use, food allergies and intolerances, appetite changes, and unintentional weight loss. The structured format ensures consistent nutritional data collection across patient encounters.

Widely used by dietitians, primary care providers, geriatric specialists, oncology teams, and hospital nutrition services, this form supports early identification of nutritional risk and facilitates personalized dietary counseling. It is appropriate for inpatient screening, outpatient wellness visits, and chronic disease management programs where nutrition plays a critical role.