Elderly Nutrition Risk Screening

Name:

Date of Birth:

Screening Date:

1. Weight Loss

Has the person unintentionally lost weight recently? Yes No Unknown

If yes, approximate amount (kg):

2. Appetite

Has the person experienced a decrease in appetite? Yes No Unknown

3. Swallowing/Chewing Difficulties

Are there any difficulties in swallowing or chewing? Yes No Unknown

If yes, provide details:

4. Mobility

Is the person able to go outside/shop for food? Yes No Partially

5. Disease/Medical Condition

Does the person have any disease or condition that affects food intake or absorption?

6. Other Risk Factors

Other relevant risk factors (e.g. social, psychological):

Assessor's Notes

Notes: