Nutrition Assessment

Circle "Yes" or "No" for each question.

I have a condition that made me change the kind or amount of food I eat.

Yes    No

I eat fewer than 2 meals per day.

Yes    No

I eat few fruits or vegetables, or milk products.

Yes    No

I have 3 or more drinks of beer, liquor or wine almost every day.

Yes    No

I have tooth or mouth problems that make it hard for me to eat.

Yes    No

I don't always have enough money to buy the food I need. 

Yes    No

I eat alone most of the time.

Yes    No

I take 3 or more different prescribed or over-the-counter drugs a day.

Yes    No

Without wanting to, I have lost or gained 10 pounds in the last 6 months. 

Yes    No

I am not always physically able to shop, cook and/or feed myself. 

Yes    No

Copyright 2004.  Robert S. Stall, MD / Stall Geriatrics.  All Rights Reserved.