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Part II Nutrition Assessment, Consequences, and Implications Figure 6.6 New Admission Questionnaire New Admission Nutrition Questionnaire

As a member of the professional team of caregivers you want to make sure your residents are as comfortable and healthy as possible in their new home. To ensure that they enjoy mealtimes and maintain their general nutritional health, here are some questions for you to ask new residents and their family to ensure proper nutrition and health.

Meals and Dining

Ask about the new resident’s eating habits: 1. Does the resident need assistance in eating meals? If so, type of assistance given

2. Does the resident have difficulty chewing or swallowing? 3. Does the resident have dental problems?

4. Does the resident enjoy dining with others? 5. Does the resident have a good appetite?

Food

Ask about the resident’s food preferences: 6. List the resident’s favorite foods 7. List the resident’s least favorite foods 8. Does the resident like spicy foods? 9. List the resident’s beverage choices for meals

10. Does the resident snack between meals? If so, favorite snacks

11. Does the resident prefer 2–3 meals a day? 12. Does the resident prefer many small meals? 13. 14. The resident’s usual main meal is

15. Does the resident have religious food guidelines? Please specify

16. Does the resident have any known food allergies? Please specify

General Health Ask about the resident’s general health and needs: 17. Does the resident have bouts of sadness or crying? 18. Does the resident appear confused at times? 19. Has the resident lost/gained weight? If so,

lbs. x time period

20. Has the resident had a decline in appetite? 21. Does the resident experience constipation? 22. Does the resident complain of diarrhea? 23. Does the resident complain of stomach pain? 24. Does the resident occasionally have nausea/vomiting? 25. Does the resident have less interest in meals? 26. Does the resident say food tastes different now?

❒ Yes ❒ Yes ❒ Yes ❒ Yes ❒ Yes ❒ Yes ❒ Yes

❒ No ❒ No ❒ No ❒ No ❒ No ❒ No ❒ No

Source: Copyright © 2001 Programs in Medicine. Reprinted by permission. Sponsored by an unrestricted educational grant from Bristol-Myers Squibb.

❒ breakfast

❒ Yes ❒ Yes

❒ Yes ❒ Yes ❒ Yes

❒ Yes ❒ Yes

❒ No ❒ No

❒ No ❒ No ❒ No

❒ lunch

❒ No ❒ No

❒ dinner

❒ Yes ❒ Yes

❒ Yes ❒ Yes ❒ Yes

❒ No ❒ No

❒ No ❒ No ❒ No

❒ Yes ❒ Yes ❒ Yes

❒ No ❒ No ❒ No