HISTORY: Weight loss in past 6 months: .kg % loss.

Change in past 2 weeks: increase no change decrease

Dietary changes: no changes changes duration..wk

If changes indicate type:
Suboptimal solid diet full liquid diet
hypocaloric liquids starvatioan

Gastrointestinal symptoms (persisting for more than weeks) none

nausea vomiting dirrhea anorexia

Functional capacity none dysfunction duration

Working suboptimally ambulatory bedridden

Disease and its relation to nutritional requirements

Primary diagnosis..............................................................................
...........................................................................................................
Metabolic demand:
No stress low stress modest stres hig stress

PHYSICAL: For each trait specify: 0 = normal. 1 =mild 2 = moderate. 3 = severe

loss of subcutaneous fat (triceps.chest) ... ankle edema ..
muscle wasting (quadriceps, deltoids) ... sacral edema .. ascites ..

SGA rating well moderatelly severely

(select one) nourished nourished malnourished
Mini Nutritional Assessment I. Screening
Name_______________:__Sex___Date_________
Age_____Weight (kg)______Height (cm)--------

A. Has food intake declined over the past there months due to loss of
appetite, digestive problems, chewing or swallowing difficulties?
0=severe loss of appetite. 1 = moderate loss of appetite, 2 = no loss of
appetite

B. Weight loss over past three months? 0 = weight loss > 3 kg; 1 = Joes not
know; 2 = weight loss of 1-3 kg; 3 = no weight loss

C. Mobility 0=bed or chair bound; 1 = able to get out of bed/chair but does
not go out; 2-goes out

D. Psychological stress or acute disease suffered in the past three months. 0 =

yes; 2 = no

E. Neuropsychological problems 0 = severe dementia or depression; I = mild

dementia; 2 = no psychological problems

F. Body Mass Index (BMI) 0=BMI < 19; 1 = BMI 19 to <21; 2 = BMI 21 to
< 23;; 3-BMI 23
Total Screening Score (Max.= 14 points.) 12 points = normal, not at risk, no
need to continue assessment; 11 points = possible malnutrition. Continue
below with II; Assessment.

Mini Nutritional Assessment II. Assessment

G. Lives independently. (Not in nursing home or hospital). 0 = no; 1 =yes

H. Prescription drugs taken (More than three drugs per day?). 0 = yes; 1 = no

I. Pressures sores or skin ulcers- 0~yes; 1 = no

J. Full meals. How many per day?; meal; 1 = 2 meals; 2 = 3 meals

K. Protein intake, (a) At least one serving of dairy products (milk, cheese,
yogurt per day (Yes/No)? (b) Two or more servings of legumes or eggs per
week (Yes/No), (c) Meat, fish, or poultry every day (Yes/No). 0.0 = if 0 or
1 yes; 0,5 = if 2 yes; 1,0 = if 3 yes

L. Fruits or Vegetables Consumes two or more servings per day? 0 = no; I =

yes

M. Fluids. Consumption of water, juice, coffee, tea, or milk per day 0.0= < 3
cups; 0.5 = 3-5 cups; 1.0 > 5 cups

N. Mode of feeding. 0= unable to eat without assistance; I = sell-fed with

some difficulty; 2= self-fed without any problem

O. Self view of nutritional status. 0 = vicws self as being malnourished; I = is

uncertain of nutritional problems

P. Health status. In comparison with ot-h-'rs in the same age group, how do
they view their health? 0~ not r.s good; 0.5= does not know; 1.0= as good;
2.0= better

Q. Mid-upper-arm circumfercnce (MUAC) in cm 0 = MUAC < 21; 0.5 =

MUAC 21-22; I = MUAC 22

R. Calf circu.nfcrence. (CC) in cm 0=CC<31: 1=CC31

I. Screening Score

II. Assessment Score

Total Malnutrition Indicator Score (max 30 points)

17-23 points at risk of malnutrition

Less than 17 points malnutrition