Nutrition Checklist for Older Adults

"DETERMINE" Mnemonic

Name: _____________________ Today's Date: _________

Possible Problem Question to Answer Score for "Yes" Answer
(Circle if "yes")
Disease Do you have an illness or condition that makes you change the kind and/or amount of food you eat? 2
Eating Poorly Do you eat fewer than 2 meals per day? 3
Do you eat few fruits, vegetables or milk products? 2
Do you have 3 or more drinks of beer, liquor or wine almost every day? 2
Tooth Loss/Mouth Pain Do you have tooth or mouth problems that make it hard for you to eat? 2
Economic Hardship Do you sometimes have trouble affording the food you need? 4
Reduced Social Contact Do you eat alone most of the time? 1
Multiple Medications Do you take 3 or more prescribed or over-the-counter drugs a day? 1
Involuntary Weight Loss/Gain Have you lost or gained 10 pounds in the last 6 months without trying? 2
Needs Assistance In Self Care Are you sometimes physically not able to shop, cook or feed yourself? 1
Elder Years > Age 80 Are you over 80 years old? 1
TOTAL ________

(from The Nutrition Screening Initiative, a project of the AAFP, ADA & NCOA, Washington, D.C. 1992.)

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