Eat Well Age Well Malnutrition Screening Data Return Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We really need your help in gathering a better picture of malnutrition prevalence rates in the community in Scotland.

The work you do with older people is vital. We hope you have been able to try out and use the malnutrition screening tools with the older people you work with.

Please can you complete this form to let us know how many older people you have spoken to this month about malnutrition.

We want to find out:
1. How many people you have raised awareness of malnutrition with
2. How many people you have identified at risk
3. How many people you have identified not at risk
4. What action you took.

1. Organisation *

2. Area of Scotland *

3. Month Screened *

4. Which tool did you use? *

Paperweight Armband

Patient Association Nutrition Checklist

5. Number of Older People Screened Age 65 to 79 *

Please enter 0 if none

6. Number of Older People Screened Age 80+ *

Please enter 0 if none

7. Number of Older People Screened Age Unknown *

Please enter 0 if none

8. Number of Older People AT RISK OF MALNUTRITION Age 65 to 79 *

Please enter 0 if none

9. Number of Older People AT RISK OF MALNUTRITION Age 80+ *

Please enter 0 if none

10. Number of Older People AT RISK OF MALNUTRITION Age Unknown *

Please enter 0 if none

11. How many AT RISK older people did you provide dietary advice e.g. Food First? *

Please enter 0 if none

12. How many AT RISK older people did you refer to the GP or Dietitian? *

Please enter 0 if none

13. How many AT RISK older people did you refer to the dentist? *

Please enter 0 if none

14. How many AT RISK older people did you signpost to community services such as a Lunch Club? *

Please enter 0 if none

15. Is there anything else you would like to tell us?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms