Nutritional Assessment Form

Nutritional Assessment Form — Form Fields

This healthcare template includes 6 fields. Conduct a comprehensive nutritional assessment for patients at risk of malnutrition or with dietary-related health conditions. Captures dietary intake, weight history, and nutritional risk factors. Supports registered dietitians in developing individualized nutrition care plans. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Current Weight and Height (text, required)
• Unintentional weight change in past 6 months (multiple choice, required) — options: No significant change, Lost 1–5% of body weight, Lost more than 5% of body weight, Gained weight unintentionally
• Appetite over the past week (dropdown selection, required) — options: Good – eating normally, Reduced – eating less than usual, Very poor – minimal intake
• Current dietary restrictions or special diets (checkboxes, optional) — options: Diabetic diet, Low sodium, Vegetarian / Vegan, Gluten-free, Texture-modified (soft / pureed), None
• Nutritional Goals and Concerns (long text, optional)