Renal Diet Intake Assessment
Patient Name
MRN/ID
Date of Assessment
Age
Sex
Female
Male
Other
Current Diagnosis
Stage of Renal Disease
CKD Stage 1
CKD Stage 2
CKD Stage 3
CKD Stage 4
CKD Stage 5
Dialysis
Transplant
Anthropometric Data
Weight (kg)
Height (cm)
BMI
Recent Weight Change
Dietary Restrictions
Usual Intake / 24hr Recall
Protein Intake (g/day)
Sodium Intake (mg/day)
Potasium Intake (mg/day)
Phosphorus Intake (mg/day)
Fluid Intake (ml/day)
Nutrition Concerns
Recommendations