Senior Nutrition Assessment Form
Personal Information
Full Name
Date of Birth
Age
Address
Phone Number
Anthropometric Data
Height (cm)
Weight (kg)
BMI
Medical History
List any medical conditions
Current medications
Nutrition Screening
Recent weight loss (past 6 months)
Appetite changes
No change
Decreased
Increased
Dietary Assessment
Food allergies / intolerances
Describe a typical day's meals
Functional Status
Difficulty with eating (chewing, swallowing, etc.)
None
Some difficulty
Significant difficulty
Notes / Additional Comments