Renal Nutrition Assessment Form
Patient Information
Name
Medical Record Number
Date of Birth
Gender
Male
Female
Other
Anthropometric Data
Height (cm)
Weight (kg)
Dry Weight (kg)
BMI (kg/m²)
Clinical Assessment
Diagnosis
Comorbidities
Fluid Status
Normal
Overhydrated
Dehydrated
Physical Signs (Edema, Muscle Wasting, etc.)
Biochemical Data
Serum Albumin (g/dL)
Serum Creatinine (mg/dL)
BUN (mg/dL)
Serum Potassium (mmol/L)
Serum Sodium (mmol/L)
Other
Dietary Assessment
Diet Order
24-Hour Dietary Recall
Appetite
Good
Fair
Poor
Nutritional Diagnosis & Plan
Nutrition Diagnosis
Nutrition Intervention / Recommendations
Assessed By
Date