Name: _____________________ Today’s Date: _________
|Possible Problem||Question to Answer||Circle for “Yes” Answer|
|Disease||Do you have an illness or condition that makes you change the kind and/or amount of food you eat?||2|
|Eating Poorly||Do you eat fewer than 2 meals per day?||3|
|Do you eat few fruits, vegetables or milk products?||2|
|Do you have 3 or more drinks of beer, liquor or wine almost every day?||2|
|Tooth Loss/Mouth Pain||Do you have tooth or mouth problems that make it hard for you to eat?||2|
|Economic Hardship||Do you sometimes have trouble affording the food you need?||4|
|Reduced Social Contact||Do you eat alone most of the time?||1|
|Multiple Medications||Do you take 3 or more prescribed or over-the-counter drugs a day?||1|
|Involuntary Weight Loss/Gain||Have you lost or gained 10 pounds in the last 6 months without trying?||2|
|Needs Assistance In Self Care||Are you sometimes physically not able to shop, cook or feed yourself?||1|
|Elder Years > Age 80||Are you over 80 years old?||1|
0-2– Good! Recheck your nutritional score in 6 months.
3-5 – You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program (eg, Meals On Wheels), senior center or health department can help. Recheck your nutritional score in 3 months.
6 or more – You are at high nutritional risk. Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health.