Nutrition Assessment Grid for Evaluating Elderly Patients

Are you evaluating an elderly patient who has been admitted to the hospital?

Yes

Age of the patient

years

Height

Weight 3 months ago

Unintentional weight loss over past 3 months

Serum albumin

Total serum cholesterol

White blood cell count

Percent lymphocytes in the peripheral blood smear (enter from 0 to 100)

Usual caloric intake

kcal

Calculated caloric needs

kcal

Does the patient have?

• nausea?

Yes

• vomiting?

Yes

• diarrhea?

Yes

• constipation?

Yes

• difficulty chewing?

Yes

• history of gastrointestinal disease?

Yes

Evaluation

Results

Please fill out required fields.

Interpretation and Description

References

Next Steps in Evaluation

Diagnosis

Specialty

Objective

ICD-10

Nutrition Assessment Grid for Evaluating an Elderly Patient for Malnutrition

Purpose: To evaluate an elderly patient admitted to the hospital for evidence of malnutrition using the detailed nutritional assessment grid of Azad et al.