Subjective Global Assessment
Scoring Sheet
Patient Name:_________________________Patient ID:_____________Date:_______________
Part 1: Medical History
SGA Score
|
1. Weight
Change |
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A |
B |
C | ||||
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A. |
Overall change in past
6 months: |
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kgs. |
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B. |
Percent change:
______
gain - |
< 5%
loss |
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_____ 5-10% loss |
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_____ > 10% loss |
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C. |
Change in past 2
weeks: ______ |
increase |
|
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| |
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______ |
no
change |
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| |
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______ |
decrease |
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2. Dietary
Intake |
|
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|
A. |
Overall change:
_______no change |
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| |
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_______change |
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| |
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B. |
Duration:
______weeks |
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C. |
Type of
change: |
|
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| |
|
|
______suboptimal solid
diet |
________ |
full liquid
diet |
|
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| |
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_______hypocaloric
liquid |
________ |
starvation |
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3. Gastrointestinal
Symptoms |
(persisting for >2
weeks) |
|
|
| ||||
|
____none |
_______nausea
_____vomiting____ |
diarrhea
|
________ |
anorexia |
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4. Functional
Impairment |
(nutritionally
related) |
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|
A. |
Overall
impairment: |
|
none
|
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|
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| |
|
|
|
|
moderate |
|
|
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| |
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|
severe |
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| |
|
B. |
Change in past 2 weeks: |
|
improved |
|
|
|
| |
|
|
|
|
no change |
|
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| |
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regressed |
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Part 2: Physical
Examination
SGA Score
|
|
|
Normal |
Mild |
Moderate |
Severe |
|
5. Evidence
of: |
Loss of subcutaneous
fat |
|
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Muscle
wasting |
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Edema |
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Ascites (hemo
only) |
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Part 3: SGA Rating (check one)
A. Well-Nourished
B. Mildly-Moderately
Malnourished
C. Severely
Malnourished