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.
Question | Answer |
---|---|
Form Name | Subjective Global Assessment Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | Kcal, Comorbidities, 3-4-5Mild, subjective global assessment sga pdf form |
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 |
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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,
Symptom: |
Frequency: * |
Duration: |
________None |
________ |
________ |
________Anorexia |
________ |
________ |
________Nausea |
________ |
________ |
________Vomiting |
________ |
________ |
________Diarrhea |
________ |
________ |
RATING: 1 2 3 4 5 6 7 |
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FUNCTIONAL CAPACITY |
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Description: |
|
Duration: |
________No Dysfunction |
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________ |
________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 |
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________Normal requirements |
________Increased requirements |
________Decreased requirements |
|
Acute Metabolic Stress: ________None |
________Low ________Moderate ________High |
RATING: 1 2 3 4 5 6 7 |
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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
Reviewed:
FAT AND MUSCLE STORE ASSESSMENT
Muscle (orange) stores Fat (blue) stores
Edema (green) should be assessed at the ankle. In
Date: ________________________________________________________
Patient Name: _________________________________________________
SGA Score: ___________________________________________________
Notes/Comments: ______________________________________________
Reviewed: