Short of breath
  Too tired
  The dwindles
  Weight loss
  Mom to be
  Very sociable
   Thanks To
 Mark W. Braun, MD

   Nutrition and Diagnosis-Related Care



The patient or caregiver should fill in these boxes.

Box 1 deals with weight changes, both acute and over the last month.

  • This section combines the data from the second sheet which looks at either 1 month or 6 month changes.
  • Click here to see that worksheet box.
  • Click here for a bigger view of the image to the right.
  • The sum of this box and the worksheet dealing with 1 month changes goes in Box 1.

Box 2 deals with food intake over the last month.

  • Again, click for a bigger view.
  • No summing, just the largest number.



Next, we deal with symptoms and activity level.

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