Subjective Global Assessment Form – Fill Out and Use This PDF

SUBJECTIVE GLOBAL ASSESSMENT RATING FORM

PATIENT NAME: ________________________________ID #:________________ DATE: _______________

WEIGHT

Baseline Weight: ________________ (Dry weight from 6 months ago)

Current Weight: _________________ (Dry weight today)

Actual Wt loss/past 6 mo.__________ % wt loss________ (actual loss from baseline/last SGA)

Wt change over past two weeks	______No change ______Increase ______Decrease
RATING: 1 2 3 4 5 6 7
	DIETARY INTAKE
______No change (Adequate)	______No change (Inadequate)
Change:

Sub optimal Intake________ Protein__________ Kcal________ Duration________

Full Liquid______________ Hypocaloric Liquid_____________Starvation ________

RATING: 1 2 3 4 5 6 7

GASTROINTESTINAL SYMPTOMS

(*Frequency: Never, daily, 2-3 times/wk, 1-2 times/wk, > 2 weeks, < 2 weeks)

Symptom:	Frequency: *	Duration:
________None	________	________
________Anorexia	________	________
________Nausea	________	________
________Vomiting	________	________
________Diarrhea	________	________
RATING: 1 2 3 4 5 6 7
	FUNCTIONAL CAPACITY
Description:		Duration:
________No Dysfunction		________
________Change in Function		________
________Difficulty with ambulation		________
________Difficulty with activity (patient specific “normal”)		________
________Light activity		________
________Bed/chair ridden with little or no activity		________
________Improvement in function		________
RATING: 1 2 3 4 5 6 7

DIAGNOSIS/CO-MORBIDITIES RELATED TO NUTRITIONAL NEEDS Primary diagnosis_______________________Comorbidities_______________________

________Normal requirements	________Increased requirements
________Decreased requirements
Acute Metabolic Stress: ________None	________Low ________Moderate ________High
RATING: 1 2 3 4 5 6 7
	PHYSICAL EXAM
________Loss of subcutaneous fat	________Some areas ________All areas
(below eye, triceps, biceps, chest)
________Muscle wasting	________Some areas ________All areas

(temple, clavicle, scapula, ribs, quadriceps, calf, knee, interosseous)

________Edema (related to undernutrition/use to evaluate weight change)

RATING: 1 2 3 4 5 6 7

OVERALL RATING

________6-7=Very Mild risk to well nourished; most categories or significant/continued improvement

________3-4-5=Mild/Moderate; No clear sign of normal status or severe malnutrition

________1-2=Severely Malnourished; most categories/significant physical signs of malnutrition

Reviewed: 04-2012

FAT AND MUSCLE STORE ASSESSMENT

Muscle (orange) stores Fat (blue) stores

Edema (green) should be assessed at the ankle. In mobility-restricted patients the edema may be visible around the eye or at the sacrum. *Remember to assess fat and muscle stores in relation to recent weight changes.

Date: ________________________________________________________

Patient Name: _________________________________________________

SGA Score: ___________________________________________________

Notes/Comments: ______________________________________________

Reviewed: 04-2012