Geriatric Nutrition Assessment Form
Patient Information
Full Name
Age
Gender
Male
Female
Other
Date
Healthcare Provider
Anthropometric Measurements
Height (cm)
Weight (kg)
BMI
Current Weight Loss (kg/%)
Usual Weight (kg)
Medical History
Relevant Diagnoses / Chronic Diseases
Medications / Supplements
Dietary Intake Assessment
Appetite
Good
Fair
Poor
Anorexic
Significant Recent Changes in Intake
Diet Type
Functional Assessment
Mobility
Independent
Assisted
Bedridden
Ability to Self-Feed
Independent
Requires Assistance
Dependent
Social and Economic Factors
Living Situation
Alone
With Family
Assisted Living
Nursing Home
Financial Limitations Affecting Nutrition
Nutritional Diagnosis / Impressions
Plan / Recommendations