Home Health Care Nutritional Assessment Sheet
Patient Details
Patient Name
Date of Birth
Assessment Date
Patient ID
Address
Anthropometric Data
Height (cm)
Weight (kg)
BMI
Usual Weight (kg)
Weight Change (last 6 months)
Dietary Assessment
Typical Daily Intake
Special Diets / Restrictions
Medical History / Clinical Data
Relevant Medical Conditions
Medications
Allergies
Physical Examination
Parameter
Finding
Comments
Muscle Mass
Fat Stores
Edema
Skin/Hair/Nail Condition
Functional Assessment
Activity Level
Assistance Needed with Feeding
Nutritional Risk Factors
Nutrition Plan / Recommendations
Assessor Name
Signature
Date