Subjective (Reports)
Usual diet (type):_______ Calorie/carbohydrate/protein/fat (g/day):_______ # of meals daily:_______
Snacks (# daily, time consumed, type):____________________________________________________________
Last meal consumed/content:____________________________________________________________________
Food preferences:_________________________________
Food allergies/intolerances:_________________________________
Cultural or religious food preparation concerns/prohibitions:___________________________________________________________________________
Usual appetite:_________________________________ Change in appetite:_______________________________
Usual weight:_________________________________
Unexpected/undesired weight loss or gain:_________________________________
Nausea/vomiting:_______ related to?_______ Heartburn/indigestion:_______ related to?_______
relieved by?_______
Chewing/swallowing problems:_________________________________ Gag/swallow reflex (present):_________________________________
Facial injury/surgery:_________________________________ Stroke/other neurologic deficit:____________________________________
Teeth: Normal:____________ Dentures (full/partial):____________ Loose/absent teeth:____________
Sore mouth/gums:____________
Dental hygiene practices:_________________________________
Professional dental care/frequency:______________________________
Diabetes/type:_________________________________
Controlled with diet/pills/insulin:_________________________________
Vitamin/food supplement use:_________________________________ Medications/herbals:__________________________________
Objective (Exhibits)
Current weight:_________________ Height:_________________ Body build:_________________
Body fat %:________________
Skin turgor (e.g., firm, supple, dehydrated):_________________
Mucous membranes (moist/dry):_________________
Edema (describe):_______ Generalized:_______ Dependent:_______ Feet/ankles:_______ Periorbital:_______ Abdominal/ascites:_______
Jugular vein distention:___________________________________________________________________________________
Breath sounds (auscultation)/location:_______ Normal:_______ Diminished:_______ Crackles:_______ Wheezes:_______
Condition of teeth/gums:______________ Appearance of tongue:______________
Mucous membranes:______________
Bowel sounds (quadrant location/type):_________________________ Hernia/masses:____________________________________________
Urine S/A or Chemstix:______________________________________
Serum glucose (Glucometer):_________________________________
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