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SUBJECTIVE GLOBAL ASSESSMENT RATING FORM Patient Name ID Date WEIGHT Baseline Weight Dry weight from 6 months ago Current Weight Dry weight today Actual Wt loss/past 6 mo. wt loss actual loss from baseline/last SGA Wt change over past two weeks No change Increase Decrease RATING 1 2 3 4 5 6 7 DIETARY INTAKE Change Sub optimal Intake Protein Kcal Duration Full Liquid Hypocaloric LiquidStarvation GASTROINTESTINAL SYMPTOMS Frequency Never daily 2-3 times/wk 1-2 times/wk 2 weeks 2 weeks Symptom Frequency Duration None Anorexia Nausea Vomiting Diarrhea FUNCTIONAL CAPACITY Description No Dysfunction Change in Function Difficulty with ambulation Light activity Bed/chair ridden with little or no activity Improvement in function DIAGNOSIS/CO-MORBIDITIES RELATED TO NUTRITIONAL NEEDS Primary diagnosisComorbidities Normal requirements Increased requirements Acute Metabolic Stress None Low Moderate High PHYSICAL EXAM Loss of subcutaneous fat Some areas All areas below eye triceps biceps chest Muscle wasting temple clavicle scapula ribs quadriceps calf knee interosseous Edema related to undernutrition/use to evaluate weight change OVERALL RATING 6-7 Very Mild risk to well nourished most categories or significant/continued improvement 3-4-5 Mild/Moderate No clear sign of normal status or severe malnutrition 1-2 Severely Malnourished most categories/significant physical signs of malnutrition Reviewed 04-2012 Fat and Muscle Store Assessment Muscle orange stores Fat blue stores Edema green should be assessed at the ankle. In mobility-restricted patients the edema may be visible around the eye or at the sacrum* Remember to assess fat and muscle stores in relation to recent weight changes. wt loss actual loss from baseline/last SGA Wt change over past two weeks No change Increase Decrease RATING 1 2 3 4 5 6 7 DIETARY INTAKE Change Sub optimal Intake Protein Kcal Duration Full Liquid Hypocaloric LiquidStarvation GASTROINTESTINAL SYMPTOMS Frequency Never daily 2-3 times/wk 1-2 times/wk 2 weeks 2 weeks Symptom Frequency Duration None Anorexia Nausea Vomiting Diarrhea FUNCTIONAL CAPACITY Description No Dysfunction Change in Function Difficulty with ambulation Light activity Bed/chair ridden with little or no activity Improvement in function DIAGNOSIS/CO-MORBIDITIES RELATED TO NUTRITIONAL NEEDS Primary diagnosisComorbidities Normal requirements Increased requirements Acute Metabolic Stress None Low Moderate High PHYSICAL EXAM Loss of subcutaneous fat Some areas All areas below eye triceps biceps chest Muscle wasting temple clavicle scapula ribs quadriceps calf knee interosseous Edema related to undernutrition/use to evaluate weight change OVERALL RATING 6-7 Very Mild risk to well nourished most categories or significant/continued improvement 3-4-5 Mild/Moderate No clear sign of normal status or severe malnutrition 1-2 Severely Malnourished most categories/significant physical signs of malnutrition Reviewed 04-2012 Fat and Muscle Store Assessment Muscle orange stores Fat blue stores Edema green should be assessed at the ankle. In mobility-restricted patients the edema may be visible around the eye or at the sacrum* Remember to assess fat and muscle stores in relation to recent weight changes..

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