Determine your Nutritional Health Checklist

Read the statements below. Circle the number in the "Yes" column for those that apply to you or someone you know. For each "Yes" answer, score the number in the box. Total your nutritional score.

YES
1. I have an illness or condition that made me change the kind and/or amount of food I eat. 
2
2. I eat fewer than two meals a day.
3
3. I eat few fruits, vegetables, or milk products.
2
4. I have three or more drinks of beer, liquor, or wine almost every day.
2
5. I have tooth or mouth problems that make it hard for me to eat.
2
6. I don’t always have enough money to buy the food I need.
4
7. I eat alone most of the time.
1
8. I take three or more different prescribed or over-the-counter drugs a day.
1
9. Without wanting to, I have lost or gained 10 pounds in the last six months.
2
10. I am not always physically able to shop, cook, and/or feed myself.
2

Total your Nutritional Score. If it’s:

0-2 Good! Recheck your score in six months. 
3-5 You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior citizens’ center, or health department can help. Recheck your score in three months.
6 or More Your are at high nutritional risk. Bring this checklist the next time you see your doctor, dietitian, or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health. 

Source: The Nutrition Screening Initiative, 1999. Used by permission.