PATIENT ASSESSMENT FORM
PATIENT DATA
Date: ANTHROPOMETRY:
Name: Height (feet/inches/cm):
Gender: Knee Height (inches/cm):
Age (Years): Current Weight (Kg):
MR# BMI:
Ward: IBW:
Soap no# ABW: (Obesity Adjustment)
OBSERVATION OF STUDENT & LEARNING WHILE COMPLETING SOAP:
1
MEDICAL HISTORY
Date of Admission:
Doctor In-Charge:
Medical Diagnosis (DX):
1.
2.
3.
4.
Past Medical History & co morbs:
Drug History:
VITAL SIGNS ASSESSMENT
Temperature: °C / °F Blood Pressure: mmHg
Heart Rate (HR): BPM Mean Arterial Pressure (MAP): mmHg
Respiratory Rate (RR): BPM O2 Saturation / Respiratory Support:
2
BIOCHEMICAL ASSESSMENT
Results
Date Tests
Elevated Normal Low
RFTs
LFTs
Lipid
Profile
CBC
ABGs
Sugar
(HBA1C)
Others
3
CLINICAL ASSESSMENT
Categories: Parameters: Findings:
Level of consciousness
Skin color
Signs of discomfort/distress
Eyes
(pupils, redness, discharge, jaundice)
Edema
(location, pitting/non-pitting)
Lips
General (color, dryness, cracking)
Appearance Gums
(color, bleeding, inflammation)
Ears
(hearing, discharge)
Nose
(discharge, congestion)
Throat/mouth
(mucous membranes, tonsils)
Neck
(swelling, thyroid)
Nausea/vomiting
Stool characteristics
(color, consistency, frequency)
Gastrointestinal
Appetite
Digestion
Fluid/Urine output
(mL, color)
Genitourinary Anuria, dysuria, oliguria, polyuria
Foley catheter / Self-voiding
4
DIET HISTORY FOOD ALLERGY/ SUPPLEMENTS
Do you have any food allergies or intolerances? If Yes, Specify: Yes / No
Have you been on a special diet? If Yes, Specify: Yes / No
Are you taking any nutritional supplements? If Yes, Specify: Yes / No
Are you taking any traditional remedies for your illness?
How many times a week do you eat the following meals?
Breakfast 7 6 5 4 3 2 1 0
Lunch 7 6 5 4 3 2 1 0
Evening tea 7 6 5 4 3 2 1 0
Dinner 7 6 5 4 3 2 1 0
How often do you eat out the following in a week?
Snacks 7 6 5 4 3 2 1 0
REMARKS:
5
24 HOUR RECALL/ USUAL INTAKE
Meal/ Snack Time Food Item Portion Size Estimated Calories Remarks
Pre-breakfast Snack
Breakfast
Mid-morning Snack
Lunch
Evening Snack
Dinner
Late-night Snack
Consistency of Meal Timings: Regular / Irregular Gap Between Meals:
Sleep Pattern (Total sleep duration/ Quality of sleep): Physical Activity (Type / Frequency / Duration):
Fluid Intake:
6
MACRONUTRIENTS & MICRONUTRIENTS EVALUATION:
Nutrients Consumed RDA Int. Nutrients Consumed RDA Int.
Total Kcal Thiamine
CHO Riboflavin
Protein Vitamin B12
Saturated Fat Iron
Poly unsaturated Fat Calcium
Cholesterol Sodium
Vitamin A Potassium
Vitamin C Phosphorous
NUTRIENT INTAKE ANALYSIS:
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CALCULATIONS
1. Body Mass Index (BMI)
Weight (kg) / Height (m2):
2. Ideal Body Weight (IBW)
Women Men
100lb for first 5 ft + 5lb for each additional inch 106lb for first 5 ft + 6lb for each additional inch
100lb for first 5 ft - 5lb for each inch below 5ft 106lb for first 5 ft - 6lb for each inch below 5ft
3. Adjusted Body Weight (ABW)
ABW = IBW + [ 0.4 * (Actual Body Weight – IBW)]
3. Basal Metabolic Rate (BMR) Mifflin Equation
[10 × wt(Kg)] + [6.25 × Ht (cm)] – [5 × Age (yrs)] - 161 [10 × wt(Kg)] + [6.25 × Ht (cm)] – [5 × Age (yrs)] + 5
4. Caloric Requirement
Mild stress: 1.2
BMR × Stress Factor × Activity Factor Moderate stress: 1.5
Severe stress: 1.8
Bedridden Factor: 1.2 - 1.5
Activity Factor: 0.9-1.1
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5. AMDR Calculation
CHO:
Protein:
Fat:
6. Caloric Deficit
Total Caloric Requirement – Present Caloric Intake
7. Fluid Intake
Fluid Intake oral:
Fluid intake IV:
Total Fluid Intake:
Fluid Requirement:
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SOAP
Subjective
Objective
Assessment
Plan
1
0
MEDICAL NUTRITION THERAPY
No. Nutritional Problem: Intervention: Expected Outcomes:
1
1
DIET PLAN
EXCHANGES, TOTAL GRAMS & CALORIES FOR DIET PLAN
Food Groups Exchanges Carbohydrates Protein Fat kcal
Milk
Fruit
Vegetable
Starch
Meat
Fat
Total Day’s Intake
------*4= ------*4= ------*9=
Calories
Total Kcal
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DIET PLAN
Time Food Items
Pre-breakfast Snack
Breakfast
Mid-morning Snack
Lunch
Evening Snack
Dinner
Late-night Snack
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ESTIMATED REQUIREMENTS:
Kcal: Fat:
CHO: Fluids:
Protein: Micronutrients:
Feeding Route: _______________________________________________________________________
Diet Order: __________________________________________________________________________
FAT AND MICRONUTRIENTS:
Nutrients Planned RDA Interpretation Nutrients Planned RDA Int.
Intake Intake
TOTAL FAT Thiamine
MUFA Riboflavin
PUFA Vitamin B12
SATURATED FAT Iron
Cholesterol Calcium
Vitamin A Sodium
Vitamin E Potassium
Vitamin K Phosphorous
Zinc
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NUTRIENT DRUG INTERACTION
G
D Drug Name: Generic Name: Mode of Action: Side Effects: Interaction with Nutrients:
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NUTRITION EDUCATION PLAN
Dietary Guidelines / Recommendations:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Name of Intern: _____________________
Remarks by Supervisor: _____________________
Signature of Supervisor: _____________________
Date: ___________
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