Personal Information

Screening

A

Has your food intake declined over the past 3 months?

B

How much weight have you lost in the past 3 months?

C

How would you describe your current mobility?

D

Have you been stressed or severely ill in the past 3 months?

E

Are you currently experiencing dementia and/or prolonged severe sadness?

Measurements (F1)

Or you may measure the circumference of your left calf.

Select your height:(feet & inches)

Select your weight: (pounds)

Your Nutritional Screening Score

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