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Leicestershire Nutrition and Dietetic Services
NUTRITION SCREENING TOOL FOOD CHART
NAME…………………………………. NHS number …………………………. WARD…………….
Please Record
(a) Type of food e.g. Cottage Pie (b) Circle amount of food eaten, for meals / snacks / supplements
Side 2
DATE: DATE:
BREAKFAST BREAKFAST
Cereal 0 1/4 1/2 3/4 All Cereal 0 1/4 1/2 3/4 All
Toast / bread (no of slices) 0 1/4 1/2 3/4 All Toast / bread (no of slices) 0 1/4 1/2 3/4 All
Marg ( ) Preserves ( ) tick if yes Marg ( ) Preserves ( ) tick if yes
Other 0 1/4 1/2 3/4 All Other 0 1/4 1/2 3/4 All
Drink 0 1/4 1/2 3/4 All Drink 0 1/4 1/2 3/4 All
SNACK
0 1/4 1/2 3/4 All
SNACK
0 1/4 1/2 3/4 All
Drink 0 1/4 1/2 3/4 All Drink 0 1/4 1/2 3/4 All
LUNCH teaplate size portion YES / NO LUNCH teaplate size portion YES / NO
Main course 0 1/4 1/2 3/4 All Main course 0 1/4 1/2 3/4 All
Potato / rice 0 1/4 1/2 3/4 All Potato / rice 0 1/4 1/2 3/4 All
Vegetable 0 1/4 1/2 3/4 All Vegetable 0 1/4 1/2 3/4 All
Dessert / fruit 0 1/4 1/2 3/4 All Dessert / fruit 0 1/4 1/2 3/4 All
Other 0 1/4 1/2 3/4 All Other 0 1/4 1/2 3/4 All
Drink 0 1/4 1/2 3/4 All Drink 0 1/4 1/2 3/4 All
SNACK
0 1/4 1/2 3/4 All
SNACK
0 1/4 1/2 3/4 All
Drink 0 1/4 1/2 3/4 All Drink 0 1/4 1/2 3/4 All
EVENING MEAL teaplate size portion YES / NO EVENING MEAL teaplate size portion YES / NO
Sandwich 0 1/4 1/2 3/4 All Sandwich 0 1/4 1/2 3/4 All
Main course 0 1/4 1/2 3/4 All Main course 0 1/4 1/2 3/4 All
Vegetable 0 1/4 1/2 3/4 All Vegetable 0 1/4 1/2 3/4 All
Potato / rice 0 1/4 1/2 3/4 All Potato / rice 0 1/4 1/2 3/4 All
Dessert / fruit 0 1/4 1/2 3/4 All Dessert / fruit 0 1/4 1/2 3/4 All
Other 0 1/4 1/2 3/4 All Other 0 1/4 1/2 3/4 All
Drink 0 1/4 1/2 3/4 All Drink 0 1/4 1/2 3/4 All
SNACK
0 1/4 1/2 3/4 All
SNACK
0 1/4 1/2 3/4 All
EVALUATION
Action taken following evaluation of 4 days intake : Qualified nurse signature..................…………………………………...
Eating well and no weight loss – discontinue Poor intake, refer to screening tool action plan Continue to monitor
Developed and produced by Leicestershire Nutrition and Dietetic Services – March 2012
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