Patient ID_______________________________________________________M      F

View form  found in Appendix A in Nutrition and Mental Health HERE

This is a suggested comprehensive assessment of nutritional status form.  Noting these nutritional and psychological descriptors has potential use in patient care for creating a treatment plan and in research for discovering and quantifying the links between nutritional status and mental status. Some items may be omitted related to the population that is being assessed (for example many individuals will not need to be assessed for phenylalanine and related metabolites or enzymes).

                It has been designed for ease in creating information and data that may be transformed to digital form (for example numerical and Yes/No answers that address a single issue).

Assessment of Nutritional Status (ANS) Related to Mental Health 

(Circle any that apply; fill in any known values)

 

ANS Aspect  0. Risk factors  Family History

Alcohol Anemia Anorexia nervosa Bipolar disorder
Cancer Depression Diabetes Food allergy
Intestinal disorder Heart Disease Hemochromatosis Kidney disease
Migraine Headaches Osteoporosis Thyroid disorder _______________
Gene analysis polymorphism (describe) ______________________________________________________

ANS Aspect 1.      Physical Status / Body Composition (circle and/or fill in blanks)

                Height: _______  Weight: _______                BMI: _______

Yes No BMI below 18.5
Yes No BMI above 30
Yes No Wt. Gain/Loss of ____ lbs in past ____ months. Loss of 10% of weight in 6 months
Yes No Muscle-Wasting
% body fat ______ Yes No Below 20% – Females / 10% – Males
Yes No Above 35%

ANS Aspect 2.      Dietary Habits

a.       ____ Eats fewer than three times a day

b.       ____ Makes food choices that do not meet the Food Guide Pyramid recommendations

Yes No 6–11 servings starches Yes No 2–3 3-oz servings meat/substitute
Yes No 3–5 servings vegetables Yes No 2–3 servings fruit
Yes No 2–3 servings dairy foods Yes No Eats mono-/polyunsaturated fats
Yes No Not over 10% calories from sugar
Yes No Not more than (F) l (M) 2 drinks alcohol/day
Yes No Low to moderate use of salt

                c. ____Consumes more than 400 mg caffeine/day

        d. ____Uses nutrient supplements:

Yes No Less than 100% DRI ____________________________________
Yes No About or equal to DRI __________________________________
Yes No More than 500% DRI or greater than UL __________________

 

ANS Aspect  3. Laboratory/ Biochemical / Metabolic (Above or Below Normal (N) range for

                           Laboratory/Biochemistry tests; Enter lab value and N value used for comparison)

Carbohydrate
___ Fasting Blood Glucose (FBS)___________ ___ 2-hour postprandial glucose (2 hr PP)     _____
___ Hemoglobin  A1c (HbA1c) _____________ ___ Galactose – enzymes and/or metabolites_____
Lipids
___ Total Cholesterol __________ ____ High Density Lipoprotein __________
___ Low Density Lipoproteins __________ ____ Triglycerides ___________________
___ EFA and/or metabolites (EPA, DHA, O-3, O-6) _______________________________________
Proteins and Amino Acids
___ Albumin ___________ ___Pre-albumin  _____    ____ BUN ______
___ Homocysteine _____ ___Phenylalanine–related enzymes and/or metabolites ________
___ Other_________________________________________________________________________
Vitamins (Blood, Serum levels, or Vitamin-Dependent Enzyme)
___ B1 (Thiamin) (TKA) ___________ ___ B2 (Riboflavin) ___________________________
___ B3 (Niacin) (Nicotinamide) ______ ___ B6 (Pyridoxine) ___________________________
___ Biotin _______________________ ___ B12 (Cobalamin) (MMA) ____________________
___ Folacin (Folic Acid) (FIGLU) ____ ___ A (Retinol) _______________________________
___ C (Ascorbic Acid) _____________ ___ D (Choleciferol) (Ergosterol) _________________
___ E (Tocopherol) ________________ ___ K (Phylloquinones) _________________________
Minerals, Elements, Electrolytes, and Heavy Metals
___ Aluminum ____________________ ___Calcium, DEXA scan ______________________
___ Chromium ____________________ ___Copper _________________________________
___ Iodine, T-3, T-4 ________________ ___ Iron, Hct, TIBC, Hemoglobin, MCV __________
___ Lead _________________________ ___ Magnesium ______________________________
___ Mercury ______________________ ___ Potassium _______________________________
___ Selenium _____________________ ___ Sodium _________________________________
___ Other ________________________ ____Other __________________________________

 

ANS Aspect  4.  Clinical Signs and Symptoms (Presence of nutrient-based lesions determined by physical

                            examination (a–e) and/or other symptoms reported by client (f–g)

                a. Oral    Tongue   Lips         Gums      Teeth   ___________

                b. Skin ______________________________________

                c. Nails _____________________________________

                d. Eyes _____________________________________

                e. Hair ______________________________________

                f. Yes       No           Diarrhea (more than two loose bowel movements/day)

                g. Yes      No           Constipation (fewer than one bowel movement every three days)

                h. Yes      No           Dental pain or discomfort that influences eating

 

ANS Aspect  5.     Nutrient  Drug Interaction (Potential for Nutrient/Drug or Drug/Nutrient interaction)
(Check those used, enter drug name if known)

___ Antacids __________________________ ___ Antianxiety ________________________
___ Antibiotic _________________________ __ Antidepressant ______________________
___ Antidepressant (Tricyclic) ____________ ___ Antidepressant (MonoAmine Oxidase Inhibitor)
______________________________________
___ Antipsychotic ______________________ ___ Antiseizure _________________________
___ Diet pills __________________________ ___ Diuretics ___________________________
___ Hypoglycemic (oral) _________________ ___ Insulin _____________________________
___ Laxative ___________________________ ___ Lipid-lowering _______________________
___ Lithium ___________________________ ___ Methotrexate ________________________
___ Tobacco ___________________________ ___ Thyroid ____________________________
___Other ______________________________ ___ Other ______________________________

                                                                                                                                                                               

Nonspecific Signs or Symptoms Reported by Client: (circle any reported; add any additional symptoms)

Appetite                           Concentration reduced                      Energy level reduced / increased

Fatigue                                   Headaches                                            Irritability              

Memory Problems               Sleep Problems                                    Tearful

_______________             ________________                                           _______________

 Additional Nutritional Observations, Comments:


 

Summarize findings of ANS by listing the risks in each stage contributing to determination of an individual’s Stage of Nutritional Injury.

                ANS 0: 0–0.9 = Risk of nutritional injury __________

                ANS 1  ____________________________________

                ANS 2  ____________________________________

                ANS 3  ____________________________________

                ANS 4  ____________________________________

                ANS 5  ____________________________________

                Non-specific signs and symptoms_______________

 Assessment of Nutritional Status: Stages of Nutritional Injury

 The Stage of Nutritional Injury (a descriptor of nutritional status) may be assigned to each individual based on any or all of the findings from the assessment and the professional judgment of the practitioner.

Use the descriptions below to determine the Stage of Nutritional Injury of the individual assessed. The highest level present is most often the designated Stage of Nutritional Injury.

 Stages of Nutritional Injury

               I.      Depletion of nutrient stores, adaptation (Potential indicated by ANS Aspects 1 and 4 )

              II.      Reserves exhausted (Potential: Stage I indicators of depletion or excesses lasting for six weeks or longer)

            III.      Physiologic and metabolic alterations (Indicated by ANS Aspect 2 )

            IV.      Nonspecific signs and/or symptoms (Potential indicated by reports of fatigue, headaches, loss of appetite, decrease in attention, insomnia, etc.)

             V.      Illness or specific signs and/or symptoms (Indicated by ANS Aspects 3 and 5)

            VI.      Damage irreversible or nonresponsive to treatment (Potentially including but not limited to loss of absorption sites resulting from bariatric surgery, bone loss, vision loss, loss of nerve function)

 Stage of Nutritional Injury: _________ (O–VI)

 GAF score ________ (date _______)                             GAF score ________ (date_______)*

 Printed name, signature and credentials of person completing the Nutritional Assessment form

_________________________________________________________________date_______________