Blank Clinical Forms

Nutritional Screen

January 11, 2017   /
Author: 
Sadie Daniels, RDN, LDN

Date:                                       Diet:
________________________           _________________________                    
Name:                                     Room #:
________________________           _________________________ 

Food allergies (also list reaction, if possible):
_______________________________________________________________________________________________

Food dislikes:
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Portion size:  Small ____________  Medium ____________  Large ____________

Breakfast

Lunch

Dinner

Cereal

 

Soup

 

Soup

 

Egg

 

Salad

 

Salad

 

Toast

 

Bread

 

Bread

 

 

 

 

 

 

 

 

 

 

 

 

 

Juice

 

Juice

 

Juice

 

Milk

 

Milk

 

Milk

 

Hot beverage

 

Hot beverage

 

Hot beverage

 

 

Questions

Verbal

  1. Do you know how tall you are?

Yes
No

  1. Do you know what you usually weigh?

Yes
No

  1. Have you had any weight changes in the past 6 months?

Yes
No

  1. If yes to #3: How much weight and why do you think the change occurred? ____________________________________________________________

 

 

  1. Do you have any cultural, religious, or ethnic food preferences?

Yes
No

  1. If yes to #5: What are they?  ________________________________________________ ____________________________________________________________________________

      

 

  1. Do you have any difficulties with your bowels?

Yes
No

  1. Do you have any chewing or swallowing difficulties?

Yes
No

  1. Do you follow a special diet at home?

Yes
No

  1. If yes to #9: What special diet?___________________________________

 

 

  1. How is your appetite? __________________________________________

 

 

  1. Do you take any vitamin, mineral, or other supplement at home?

 

Yes
No

  1. If yes to #12, please describe. ____________________________________

 

 

  1. Do you have any problems with heartburn or reflux?

Yes
No

  1. If yes to #13: Do you take medication for this?
    If you take medication for this, is it effective?

Yes
No

Yes
No

Please place any additional comments on the back of this form.

 Signature of RD, RDN, or DTR: _________________________________