Page 22 - Avoid Food and Drug Interactions

KINGDOM OF SAUDI ARABIA File No: ……………….…………

Ministry of Health Patient Name: …………………
ID ……………………..…….….
Region…………………..
Hospital:….. ……………

Nutritional Screening Form

ADULT INFANT TODDLER/CHILD/ADOLESCENT

 Poor appetite > 3days  Poor/Inappropriate intake.  Poor appetite > 3days
 Patient on Clear liquid diet, full liquid  Patient on Clear Liquid diet, full  Patient on Clear liquid diet, full liquid

diet, or NPO for more than 72 ours liquid diet, or NPO for more than 72 diet, or more than 72 hrs.
 Age is greater than 75 years.  Failure to thrive.
 Difficulty with swallowing/ hrs.  Weight for Height is less than 5
 Failure to thrive.
chewing/Mouth Ulcers.  Less than 35 weeks gestation. percentile.
 Gluten free, Glucose 6 Phosphate  Insufficient Weight gain.  Weight for Height is greater than 95

Dehydrogenase, Lactose.  Gastrointestinal Dysfunction percentile.
 BMI is less than 14.
Intolerance (Diarrhea, vomiting) is greater than 2  Significant weight loss what is more

 Psychological eating disorders. days. than 2% of body weight per week.
 Difficulty in swallowing / chewing.
 Gastrointestinal Dysfunction  Therapeutic Formula.  Gastrointestinal Dysfunction (Diarrhea,
 Metabolic disorders such as Cow's
Vomiting greater than 3 days.
(Diarrhea vomiting etc) more than 3 milk allergy, gluten free, Glucose 6  Eating disorders (anorexia, bulimia).
 Inborn errors of metabolic.
days. phosphate Dehydrogenase, Lactose  Oncology patient on chemotherapy or
 Medical problems with special diet
intolerance. Urea Cycle Disorder. radiology poor appetite and

requirements (DM,HTN, Cardiac, Homcystinuria, Phenylketoauria, underweight.
 Major surgery (Gastrointestinal tract
Renal, Hepatic failure). Maple Storage Disease,
 High risk pregnancy: (Hyperemesis, surgery … etc).
 Major surgery (brain surgery,  Pressure Ulcers.
 Tube feeding.
pregnancy Induced). Gastrointestinal surgery, head and  Terminal/ palliative care.
 Hepatic Failure.
 Hypertension, Pre-Eclampsia jaw surgery, open heart surgery).  Food and drug Interaction.
 Albumin <25 mg/di
toxemia, Blood disorders,  Pressure Ulcers.

Gestational Diabetes Mellitus,  Tube feeding.
 Terminal/palliative care.
Multiple Pregnancy, Pregnancy

complicated with medical disorders,  Very low birth weight is less than

pregnant BMI>40). 1.8kg.
 Mouth Sores and Ulcers.
 Lactating with special diet needs,

lactating BMI>40.
 Obesity BMI>35.
 Underweight BMI is less than 18.5.

 Tube Feeding.
 Pressure Ulcers.
 Oncology patient on chemotherapy

or radiotherapy with poor appetite

and underweight.
 Major surgery (Gastrointestinal tract

surgery … ect).

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