Objective Assessment
Demographics
Name MR #
Physician Age
Gender Admit Date
Diagnosis
Medical History
Condition Yes Date of Diagnosis Condition Yes Date of Diagnosis
Irritable Bowel Syndrome Type 1 Diabetes
Inflammatory Bowel Disease Type 2 Diabetes
Crohn’s Disease Metabolic Syndrome
Ulcerative Colitis Hypoglycaemia
Coeliac Disease Hyperglycaemia
Gastric/Peptic Ulcer Hyperthyroidism
GERD Hypothyroidism
Hepatitis C/Liver Disease PCOS
Food Intolerance Infertility
Heart Attack Kidney Stones
Stroke UTI
Elevated Cholesterol Yeast Infection
Hypertension Cancer (identify type)
Osteoarthritis
Chronic Pain Fibromyalgia
Family History
Condition Yes Age of Onset Description Family Member
Heart Disease
Diabetes
Hypertension
Stroke
Obesity
Cancer
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
ANTHROPOMETRIC MEASUREMENTS
Weight lbs ÷ 2.2 kg
Height inches x 2.54 cm
Body Mass Index (BMI) ABW (kg) ÷ Height² (m²) kg/m²
Usual Body Weight lbs ÷ 2.2 kg
Ideal Body Weight (IBW)
Female 100lbs for 5ft + 5 x inches above 5ft lbs
Weight in lbs ÷ 2.2 kg
Male 106lbs for 5ft + 6 x inches above 5ft lbs
Weight in lbs ÷ 2.2 kg
% IBW ( ABW ÷ IBW ) x 100
Waist Circumference inches x 2.54 cm
Hip Circumference inches x 2.54 cm
Wrist Size cm
Waist to Hip Ratio Waist Circumference ÷ Hip Circumference
cm
Mid Upper Arm Circumference (MUAC) cm
Body Fat Mass % x ABW (lbs) lbs ÷ 2.2 kg
Body Fat Free Mass ABW (lbs) - FM lbs ÷ 2.2 kg
Mid Arm Muscle Circumference (MAMC) MUAC (cm) - [Triceps Skinfold (mm) x 0.314]
cm
Weight Adjustments
Amputation ABW - (% adjustment x ABW) kg
Mild Oedema ABW (kg) - (2-3kg) kg
Demi-Span
Female (16-54 yrs) [1.3 x Demispan (cm)] + 62 cm
Male (16-54 yrs) [1.3 x Demispan (cm)] + 68 cm
Knee Height
Female (18-60 yrs) [1.87 x Knee Height (cm)] + 70.25 cm
Male (18-60 yrs) [1.88 x Knee Height (cm)] + 71.85 cm
Ulna Length cm
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
Skinfold Measurements Measurement Site Reading 1 Reading 2 Reading Average
Triceps cm cm cm
Biceps cm cm cm
Subscapular cm cm cm
Suprailiac cm cm cm
ANTHROPOMETRIC INTERPRETATIONS
Body Mass Index (BMI) kg/m²
Interpretation
Ideal Body Weight (IBW) kg
Interpretation
Waist Circumference cm
Interpretation
Wrist Circumference for Frame Size
Interpretation
Mid Upper Arm Circumference (MUAC) cm
Interpretation
Demi-Span cm
Interpretation
Ulna Length cm
Interpretation
Skinfold Measurements
Interpretation
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
BIOCHEMICAL ASSESSMENT
Test Results Normal Range Nutritional Association
Hb
Total RBCs
Hct
MCV
MCH
MCHC
Platelet Count
WBC
Bilirubin
ALT
AST
ALP
Total Protein
Albumin
A/G Ratio
Urea
BUN
Creatinine
eGFR
Total Calcium
PO4
Sodium
Potassium
Magnesium
Serum Chloride
HCO3
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
NUTRITIONAL INTERVENTION
Nutrient RDA Sources
Vitamin A
Vitamin D
Vitamin E
Vitamin K
Thiamine
Riboflavin
Nicotinamide
Pantothenic Acid
Pyridoxine
Biotin
Folate
Cobalamin
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
NUTRITIONAL INTERVENTION
Nutrient RDA Sources
Ascorbic Acid
Iron
Calcium
Phosphorus
Sodium
Chloride
Potassium
Magnesium
Selenium
Copper
Zinc
Iodine
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
CLINICAL SIGNS & SYMPTOMS
Sign/Symptom Possible Nutrition-Related Causes Possible Non-Nutrition Causes
Hair
Alopecia
Colour changes,
depigmentation
Easily plucked, dull, dry,
lack of shine
Corkscrew hair,
unmerged coiled hairs,
swan neck shape
Flag sign (alternate dark
and light hairs)
Lanugo (very fine, soft
hair)
Eyes
Xanthelasma,
circumferential arcus
Angular blephritis
Pale conjunctiva
Night blindness, dry
membranes, dull/soft
cornea, infected,
ulcerated eye -
Keratomalacia
Angular palpebritis, red/
inflamed conjunctiva
swollen/sticky eyelids
Ring of fine blood vessels
around cornea
Bitot’s spots
Ophthalmoplegia
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
CLINICAL SIGNS & SYMPTOMS
Sign/Symptom Possible Nutrition-Related Causes Possible Non-Nutrition Causes
Face
Skin colour loss, dark
cheeks & under eyes,
Scaling of skin around
nostrils
Pallor
Hyperpigmentation
Enlarged parotid gland
Lips
Soreness, burning, pale
Tongue
Sore, swollen, raw-beefy
red tongue
Sore, burning, purple-ish
Smooth, beefy red tongue
Glossitis
Pale tongue
Gums
Gingivitis, swollen,
spongy, retracting,
bleeding
Taste
Hypogeusia; dysgeusia
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
CLINICAL SIGNS & SYMPTOMS
Sign/Symptom Possible Nutrition-Related Causes Possible Non-Nutrition Causes
Nails
Beau’s lines
Muehrcke’s lines
Koilonychia
Splinter hemorrhage
Brittle, soft, dry, weak or
thin; split easily
Central ridges
Neck
Thyroid enlargement;
goiter
Skin
Slow wound healing,
decubitus ulcers
Acanthosis nigricans
Psoriasis
Eczema
Follicular hyperkeratosis
Seborrheic dermatitis
Petechiae
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
CLINICAL SIGNS & SYMPTOMS
Sign/Symptom Possible Nutrition-Related Causes Possible Non-Nutrition Causes
Skin contd.
Purpura
Xerosis
Perifollicular hemorrhage
Dryness, sandpaper feel,
flakiness
Pellagra
Lack of fat under skin,
cellophane appearance
Bilateral oedema
Yellow pigmentation
Yellow to Orange
pigmentation
Cutaneous flushing
Body oedema, round
swollen face
Pallor, fatigue, depression
Poor skin turgor
Gastrointestinal
Anorexia, flatulence,
diarrhoea
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
CLINICAL SIGNS & SYMPTOMS
Sign/Symptom Possible Nutrition-Related Causes Possible Non-Nutrition Causes
Skeletal System
Bone demineralization
Epiphyseal enlargement
of wrists, legs, knees,
bowed legs, rickets or
osteomalacia, frontal
bossing
Bone tenderness/pain
Muscular System
Weakness
Wasted appearance
Calf tenderness, absent
deep tendon reflexes, foot
and wrist drop
Peripheral neuropathy,
tingling, ‘pins & needles’
Muscle twitching, tetany
Muscle cramps
Muscle pain
Nervous System
Inability to concentrate,
defective memory;
Confabulation;
Disorientation
Peripheral neuropathy
with weakness and
paraesthesias; Ataxia and
decreased tendon
reflexes
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
Dietary Assessment
Have you gained or lost weight in the last 30 days? yes no
Explain, if yes
Gut Health Data
Sign/Symptom Yes Date of onset Sign/Symptom Yes Date of onset
Abdominal Pain Constipation
Epigastric Pain Diarrhoea
Heartburn Alternate loose/solid stool
Regurgitation Steatorrhoea
Bloating Loose Stool
Empty Feeling Early Satiety
Nausea Lethargy
Vomiting Pain when Hungry
Loss of Appetite Postprandial Pain
Belching Fluid Retention
Flatulence Loss of Taste
Haematemesis Mouth Sores
Dysphagia Swollen Tongue
Painful Stool
Allergies
Allergy Yes Description Symptoms
Food
Medication
Supplement
Environment
Supplement (Food/Nutrient)
Supplement Name Dose Reason Frequency
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
Dietary Assessment
Smoking
Yes No Occasional Chain
Fluid Intake
Drink Frequency/day Drink Frequency/day
Water Soda
Coffee Diet Soda
Tea Other
Meal Patterns
Frequency/ week Location of Meal (Home/Outside)
Main Meal Weekend
Snack Weekend
Main Meal Weekdays
Snack Weekdays
Management of Symptoms
Symptom Management
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
Dietary Assessment
24 Hour Recall
Meal Food Eaten Amount/Serving
Breakfast
Lunch
Dinner
Snacks
Nutritional Calculations of Dietary Intake - 24 Hour Recall
Energy Carbohydrates Protein Fats
Group Exchanges Others
(kcal) (g) (g) (g)
Starch
Fruits
Milk & Dairy
Non-Starchy
Vegetables
Meat & Meat
Substitutes
Fats
Miscellaneous
Total
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
Dietary Assessment
Usual Dietary Intake
Meal Food Eaten Amount/Serving
Breakfast
Lunch
Dinner
Snacks
Nutritional Calculations of Dietary Intake - Usual Dietary Intake
Energy Carbohydrates Protein Fats
Group Exchanges Others
(kcal) (g) (g) (g)
Starch
Fruits
Milk & Dairy
Non-Starchy
Vegetables
Meat & Meat
Substitutes
Fats
Miscellaneous
Total
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
Medications
Name of Drug Class of Drug Dosage/Frequency Drug-Nutrient Interactions
HAMEED LATIF HOSPITAL Department of Clinical Nutrition
CARE, CONCERN, COMPASSION Internship Program
created by
Syeda Zainab Abbas
