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Nutrition checklist
The warning signs of poor nutritional health are often overlooked. Use this checklist to find out if you or someone you know is at nutritional risk.
Read the statements below. Circle the number in the YES column for those that apply to you or someone you know. For each yes answer, score the number in the box. Total your nutritional score and review suggestions to improve your nutritional health.
| Question |
YES |
| I have an illness or condition that made me change the kind and/or amount of food I eat. |
2 |
| I eat fewer than two meals per day. |
3 |
| I eat few fruits, vegetables or milk products. |
2 |
| I have three or more drinks of beer, liquor or wine almost every day. |
2 |
| I have tooth or mouth problems that make it hard for me to eat. |
2 |
| I don't always have enough money to buy the food I need. |
4 |
| I eat alone most of the time. |
1 |
| I take three or more different prescribed or over-the-counter drugs a day. |
1 |
| Without wanting to, I have lost or gained 10 pounds in the last six months. |
2 |
| I am not always physically able to shop, cook and/or feed myself. |
2 |
| TOTAL = |
_____ |
Note: This questionnaire is part of the Nutrition Screening Initiative, a project of the American Academy of Family Physicians, American Dietetic Association and National Council on Aging. Funded in part by a grant from Ross Products Division, Abbott Laboratories.
If your score is:
- 0-2 - Good! Recheck your nutritional score in six months.
- 3-5 - You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizens center or health department can help. Recheck your nutritional score in three months.
- 6 or more - You are at high nutritional risk. Bring this checklist the next time you see your doctor, dietician or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health.
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