Subjective Global Assessment Form PDF Details

Are you a healthcare professional looking for an efficient and comprehensive way to assess your patients? Introducing subjective global assessment (SGA) – a simple, evidence-based form that can be used to evaluate nutritional status in any health setting. Used consistently over time, this versatile tool can help you better understand the overall nutritional and medical condition of each individual patient. Keep reading if you'd like to learn more about SGA and how it can provide valuable insight into the long-term needs of your patients.

QuestionAnswer
Form NameSubjective Global Assessment Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesKcal, Comorbidities, 3-4-5Mild, subjective global assessment sga pdf form

Form Preview Example

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