Complete the screening section by clicking on the questions and selecting the appropriate answer. If score is 11 or less, the form will continue with the assessment to gain a Malnutrition Indicator Score.
select severe loss of appetite moderate loss of appetite no loss of appetite
select weight loss greater than 3 kg (6.6 lbs) does not know weight loss between 1 and 3 kg (2.2 and 6.6 lbs) no weight loss
select bed or chair bound able to get out of bed/chair does not go out goes out
select yes no
select severe dementia or depression mild dementia no psychological problems
(weight in kg) / (height in m)2 =
