Adolescent Nutrition Assessment Format

10–18 Years — Growth & Puberty Nutrition

Used by dietitians, nutrition students, hospitals and health workers across India.

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What the format covers

Patient Profile

  • Registration / OPD No.
  • Date of Assessment
  • Patient Name
  • Age (years)
  • Gender
  • Contact No.
  • Address
  • Referred By
  • Ward / Bed No.
  • Occupation
  • Education
  • Modified Kuppuswamy scale class
  • Medical diagnosis / chief complaint
  • Past medical & surgical history
  • Family history
  • Physical activity level (ICMR-NIN 2020)

Growth & Pubertal Assessment

  • Tanner Stage (Pubertal Stage)
  • Age at Menarche (Girls) (years)
  • Menstrual Regularity
  • Physical Activity Level
  • Screen Time (hours/day)
  • Sleep Duration (hours/night)

Anthropometric Measurements

  • Height (cm)
  • Weight (kg)
  • BMI (kg/m²)
  • MUAC (Mid-Upper Arm Circumference) (cm)
  • Waist Circumference (cm)
  • Hip Circumference (cm)
  • Waist-Hip Ratio (WHR)
  • Usual body weight (kg)
  • % weight change (%)
  • Body Fat % (%)
  • Ideal Body Weight (kg)
  • WHO 2007 BMI-for-age classification
  • WHO 2007 BMI-for-age z-score (reference chart) (SD)
  • Height-for-age z-score (reference chart) (SD)
  • WHO 2007 height-for-age classification

Clinical Investigations

  • Haemoglobin (g/dL)
  • Serum Ferritin (ng/mL)
  • Vitamin D (25-OH) (ng/mL)
  • Serum Calcium (mg/dL)
  • TSH (mIU/L)
  • Fasting Blood Glucose (mg/dL)

Eating Behaviour & Concerns

  • Eating Habits
  • Body Image Concern
  • Anaemia Signs
  • Nutritional Deficiency Signs

Dietary Assessment

  • Diet Type
  • No. of Meals/Day
  • Appetite
  • Food Allergy / Intolerance
  • Food Aversions
  • Food Preferences
  • Water Intake (litres/day)
  • Alcohol Consumption
  • Tobacco Use
  • 24-hour dietary recall — table: Time, Meal, Food / dish, Ingredients, Household measure, Approx. quantity (g/mL)
  • Food frequency — table: Frequency, Usual portion
  • Nutritional Supplements

Adolescent preventive & psychosocial screening

  • Weekly IFA (Anaemia Mukt Bharat / WIFS)
  • SCOFF: Do you make yourself sick because you feel uncomfortably full?
  • SCOFF: Do you worry you have lost control over how much you eat?
  • SCOFF: Have you recently lost more than one stone (6.35 kg) in 3 months?
  • SCOFF: Do you believe yourself to be fat when others say you are too thin?
  • SCOFF: Would you say that food dominates your life?
  • SCOFF screen
  • HEADSS notes (Home, Education, Activities, Drugs, Sexuality, Suicide / safety)

Nutrition Diagnosis & Risk Stratification

  • Nutritional status (age-specific clinical assessment)
  • Overweight/obesity status
  • PES: Problem
  • PES: Etiology (Related to)
  • PES: Signs & Symptoms (Evidenced by)

Nutrition Care Plan & Recommendations

  • Energy Requirement (clinician prescribed) (kcal/day)
  • Protein Requirement (g/day)
  • Special Nutrient Focus
  • Dietary Advice / Modifications
  • Sample Meal Plan Given?
  • Next Follow-Up Date
  • Counselling Notes
  • Monitoring & Evaluation — table: Indicator, Baseline, Target, Review date, Outcome

Diet Prescription (filled by dietitian)

  • Prescribed energy (kcal/day)
  • Prescribed protein (g/day)
  • Prescribed fluid (mL/day)
  • Diet type / consistency
  • Restrictions
  • Meal plan — table: Time, Food / dish, Quantity (household measure)
  • Foods to include
  • Foods to avoid
  • Prescribed by (name, reg. no.)

Signature

  • Dietitian Name & Signature

Automatic scores in this form

  • BMI
  • Waist-Hip Ratio (WHR)
  • % weight change
  • WHO 2007 BMI-for-age classification
  • WHO 2007 height-for-age classification
  • SCOFF screen

All calculated values are indicative — clinical judgement required.

Standards & references

  • WHO Growth Reference 2007
  • RKSK
  • Anaemia Mukt Bharat / WIFS
  • SCOFF
  • GLIM 2019
  • Nutrition Care Process (ADIME)

Frequently asked questions

What is included in the Adolescent Nutrition Assessment format?

The format has 11 sections: Patient Profile; Growth & Pubertal Assessment; Anthropometric Measurements; Clinical Investigations; Eating Behaviour & Concerns; Dietary Assessment; Adolescent preventive & psychosocial screening; Nutrition Diagnosis & Risk Stratification; Nutrition Care Plan & Recommendations; Diet Prescription (filled by dietitian); Signature. It also calculates 6 values automatically, such as BMI, Waist-Hip Ratio (WHR), % weight change.

Which guidelines does the Adolescent Nutrition Assessment follow?

It follows WHO Growth Reference 2007, RKSK, Anaemia Mukt Bharat / WIFS, SCOFF, GLIM 2019, Nutrition Care Process (ADIME). All calculated values are indicative — clinical judgement is required.

Can I download the Adolescent Nutrition Assessment as a PDF?

Yes. After a free sign-up you can fill the form online and download both blank and filled A4 PDFs, and save private case sheets for your patients.

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