Geriatric Nutrition Assessment Format

Elderly Nutrition (>60 Years)

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)

Functional & Geriatric Assessment

  • Living Arrangement
  • ADL (Activities of Daily Living)
  • Mobility
  • Chewing / Swallowing Difficulty
  • Dentures
  • Cognitive Status (MMSE/Screening)
  • Depression Screening (GDS)
  • Falls Risk
  • Polypharmacy (≥5 drugs)
  • Current Medications (list)

MNA (Mini Nutritional Assessment)

  • Has food intake declined in last 3 months?
  • Weight Loss in Last 3 Months
  • Mobility
  • Psychological Stress/Acute Disease in last 3 months
  • Neuropsychological Problems
  • F. BMI (or calf circumference if BMI unavailable)
  • MNA-SF Screening Score (0–14)
  • MNA-SF Category

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)
  • Waist risk (Asian cut-off)
  • Waist-to-height ratio
  • Usual body weight (kg)
  • % weight change (%)
  • Body Fat % (%)
  • Ideal Body Weight (kg)
  • BMI Category (Asia-Pacific)

Geriatric Investigations

  • Haemoglobin (g/dL)
  • Serum Albumin (g/dL)
  • Vitamin D (25-OH) (ng/mL)
  • Vitamin B12 (pg/mL)
  • Serum Folate (ng/mL)
  • Serum Calcium (mg/dL)
  • Serum Creatinine (mg/dL)
  • Fasting Blood Glucose (mg/dL)
  • TSH (mIU/L)
  • Bone Mineral Density (DEXA T-Score)
  • Handgrip Strength (kg)

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

Full MNA (assessment items G–R)

  • Full MNA item F — BMI (required if SF used calf substitution)
  • G. Lives independently (not nursing home / hospital)
  • H. More than 3 prescription drugs/day
  • I. Pressure sores or skin ulcers
  • J. Full meals/day
  • K. Protein markers: dairy daily; legumes/eggs ≥2/week; meat/fish/poultry daily
  • L. ≥2 servings fruit / vegetables per day
  • M. Daily fluids (cups; includes all beverages)
  • N. Mode of feeding
  • O. Self-view of nutritional status
  • P. Health compared to same-age peers
  • Q. Mid-arm circumference
  • R. Calf circumference
  • Full MNA total /30

Sarcopenia & swallowing assessment

  • AWGS 2019 low grip screen
  • Calf circumference (cm)
  • AWGS calf circumference screen
  • SARC-F score
  • SARC-F screen
  • IDDSI diet level (clinician / swallowing specialist assigned)

Nutrition-Focused Physical Examination (NFPE)

  • Muscle wasting
  • Subcutaneous fat loss
  • Oedema
  • Hair
  • Eyes
  • Mouth
  • Skin
  • Nails
  • Goitre

Nutrition Diagnosis & Risk Stratification

  • GLIM 2019 — phenotypic criteria
  • GLIM 2019 — etiologic criteria
  • GLIM malnutrition
  • GLIM severity (assessor confirmed)
  • Overweight/obesity status
  • PES: Problem
  • PES: Etiology (Related to)
  • PES: Signs & Symptoms (Evidenced by)

Nutrition Care Plan & Recommendations

  • Energy Requirement (clinician prescribed) (kcal/day)
  • Reference (guideline) — dietitian to prescribe: Energy (ICMR-NIN 2020, healthy-adult baseline only; indicative — adjust clinically) (kcal/day)
  • Reference (guideline) — dietitian to prescribe: Protein (ICMR-NIN 2020 adult 0.83 g/kg; healthy-adult baseline only, indicative — adjust clinically) (g/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

  • MNA-SF Screening Score (0–14)
  • MNA-SF Category
  • BMI
  • Waist-Hip Ratio (WHR)
  • Waist risk (Asian cut-off)
  • Waist-to-height ratio
  • % weight change
  • BMI Category (Asia-Pacific)
  • Full MNA total /30
  • AWGS 2019 low grip screen
  • AWGS calf circumference screen
  • SARC-F screen
  • GLIM malnutrition
  • Reference (guideline) — dietitian to prescribe: Energy (ICMR-NIN 2020, healthy-adult baseline only; indicative — adjust clinically)
  • Reference (guideline) — dietitian to prescribe: Protein (ICMR-NIN 2020 adult 0.83 g/kg; healthy-adult baseline only, indicative — adjust clinically)

All calculated values are indicative — clinical judgement required.

Standards & references

  • MNA-SF (Nestlé Nutrition Institute)
  • Full MNA
  • ESPEN geriatrics 2022
  • AWGS 2019
  • IDDSI
  • GLIM 2019
  • Nutrition Care Process (ADIME)

Frequently asked questions

What is included in the Geriatric Nutrition Assessment format?

The format has 13 sections: Patient Profile; Functional & Geriatric Assessment; MNA (Mini Nutritional Assessment); Anthropometric Measurements; Geriatric Investigations; Dietary Assessment; Full MNA (assessment items G–R); Sarcopenia & swallowing assessment; Nutrition-Focused Physical Examination (NFPE); Nutrition Diagnosis & Risk Stratification; Nutrition Care Plan & Recommendations; Diet Prescription (filled by dietitian); Signature. It also calculates 15 values automatically, such as MNA-SF Screening Score (0–14), MNA-SF Category, BMI.

Which guidelines does the Geriatric Nutrition Assessment follow?

It follows MNA-SF (Nestlé Nutrition Institute), Full MNA, ESPEN geriatrics 2022, AWGS 2019, IDDSI, GLIM 2019, Nutrition Care Process (ADIME). All calculated values are indicative — clinical judgement is required.

Can I download the Geriatric 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.