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Outdoor Nutritional Assessment

Assessment

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2020-nde-031
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36 views2 pages

Outdoor Nutritional Assessment

Assessment

Uploaded by

2020-nde-031
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FATIMA MEMORIAL HOSPITAL,

SHADMAN, LAHORE

NUR-FMS
School of Nutrition

OUTDOOR NUTRITIONAL ASSESSMENT AND


RECOMMENDATION FORM

Date: _______________
Patient Name: __________________________________________ Contact No.:__________
Age: _______ Height: _______ Weight: _______ BMI: _____________ IBW: _____________
Nutritional Diagnosis: _____________________________________________________________

Weight History
 No Change  Increased  Decreased
Diet History
Food Item Quantity Type
Milk Products
Meat
Vegetables
Fruits
Bread and Cereals
Fat / Cooking Oil
Water Intake
Glasses / Day
Temperature
How often do you consume the following in a week?
Carbonated Beverages
Bakery Products
Fast Food
Sleep-Wake Cycle
Wake up Time
Sleep Time
Meal Timings Meals Frequently Skipped
Breakfast Time Breakfast
Lunch Time Lunch
Dinner Time Dinner
Physical Examination
Edema Skin
Muscle wasting Mouth
Hair Nails
Eyes Teeth
GI Function
Appetite Vomiting
Nausea Diarrhea
Anorexia Constipation
Others Duration
Exercise & Walk
Type of Exercise
Duration
Metabolic Stress
No Stress Moderate
Low High
Biochemical Findings
Date Test Result Date Test Result

SGA Rating
 Well-Nourished  Moderately Malnourished  Severely Malnourished
Recommendations
Caloric Requirement
Fluid Requirement
Preferred Feeding Route
Mechanism of Diet
Type of Diet
Supplement
Follow up Notes

________________________
Dietitian
NUR-FMS School of Nutrition

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