The Nutrition Screening Initiative Checklist was developed as a self-administered questionnaire to screen older patients for nutritional risk factors.
illness or condition that has caused a change in the kind and/or amount of food consumed
eat fewer than 2 meals per day
eat few fruits or vegetables or milk products.
3 or more drinks of beer, liquor or wine almost every day.
tooth or mouth problems that make it hard to eat.
don't always have enough money to buy needed food
eat alone most of the time
3 or more different prescribed or over-the-counter drugs taken daily.
unexplained loss or gain of 4.5 kilograms (10 pounds) in the last 6 months.
not always physically able to shop, cook and/or feed self
total score =
= SUM(points for all 10 statements)
• minimum score: 0
• maximum score: 21
0 – 2
Recheck your nutritional score in 6 months.
3 – 5
See what can be done to improve your eating habits and lifestyle. Recheck your nutritional score in 3 months.
Bring this checklist the next time you see your doctor, dietitian, social worker or other qualified health professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health.
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