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Nutritional Assessment Form - Free Healthcare Template | ZenBuild | ZenBuild

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Nutritional Assessment Form

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.

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Nutritional Assessment Form

Complete this nutritional assessment to guide your dietary care plan.

Patient Name*

Current Weight and Height*

Unintentional weight change in past 6 months*

No significant changeLost 1–5% of body weightLost more than 5% of body weightGained weight unintentionally

Appetite over the past week*

Current dietary restrictions or special diets

Diabetic dietLow sodiumVegetarian / VeganGluten-freeTexture-modified (soft / pureed)None

Nutritional Goals and Concerns

Template Details

CategoryHealthcare

IndustryHealthcare

Fields6

Uses0

Views1

healthcarenutritiondietitianassessmentpatient