Self-MNA - MNA® Elderly

Self-MNA ®Mini Nutritional AssessmentFor Adults 65 years of Age and OlderLast name:Date:First name:Age:Complete the screen by filling in the boxes with the appropriatenumbers. Total the numbers for the final screening score.ScreeningA Has your food intake declinedover the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriatenumber (0, 1, or 2) in the box to the right.B How much weight have youlost in the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriatenumber (0, 1, 2 or 3) in the box to theright.C How would you describeyour current mobility?[ENTER ONE NUMBER]Please enter the mostappropriate number (0, 1, or 2) inthe box to the right.D Have you been stressed orseverely ill in the past 3months?[ENTER ONE NUMBER]Please enter the most appropriatenumber (0 or 2) in the box to the right.E Are you currently experiencingdementia and/or prolongedsevere sadness?[ENTER ONE NUMBER]Please enter the most appropriatenumber (0, 1, or 2) in the box to the right.0 = severe decrease in food intake1 = moderate decrease in food intake2 = no decrease in food intake0 = weight loss greater than 3 kg1 = do not know the amount of weight lost2 = weight loss between 1 and 3 kg3 = no weight loss or weight loss lessthan 1 kg0 = unable to get out of a bed, a chair,or a wheelchair without theassistance of another person1 = able to get out of bed or a chair, butunable to go out of my home2 = able to leave my home0 = yes2 = no0 = yes, severe dementia and/orprolonged severe sadness1 = yes, mild dementia, but noprolonged severe sadness2 = neither dementia nor prolongedsevere sadness[[Please total all of the numbers you entered in the boxesfor questions A-E and write the numbers here:

Now, please CHOOSE ONE of the following two questions – F1 or F2 – to answer.Question F1Height (cm)147.5150152.5155157.5160162.5165167.5170172.5175177.5180182.5185187.5190192.5GroupLess than 41.1Less than 42.8Less than 44.2Less than 45.6Less than 47.1Less than 48.6Less than 50.2Less than 51.7Less than 53.3Less than 54.9Less than 56.5Less than 58.2Less than 59.9Less than 61.6Less than 63.3Less than 65.0Less than 66.8Less than 68.6Less than 70.40Body Weight (kg)41.1 – 45.342.8 – 47.244.2 – 48.745.6 – 50.447.1 – 52.048.6 – 53.750.2 – 55.451.7 – 57.153.3 – 58.854.9 – 60.656.5 – 62.458.2 – 64.259.9 – 66.161.6 – 67.963.3 – 69.865.0 – 71.866.8 – 73.768.6 – 75.770.4 – 77.7145.4 – 49.647.3 – 51.748.8 – 53.450.5 – 55.252.1 – 57.053.8 – 58.855.5 – 60.657.2 – 62.558.9 – 64.460.7 – 66.462.5 – 68.364.3 – 70.366.2 – 72.468.0 – 74.469.9 – 76.571.9 – 78.673.8 – 80.875.8 – 82.977.8 – 85.1249.7 or more51.8 or more53.5 or more55.3 or more57.1 or more58.9 or more60.7 or more62.6 or more64.5 or more66.5 or more68.4 or more70.4 or more72.5 or more74.5 or more76.6 or more78.7 or more80.9 or more83.0 or more85.2 or more3Please refer to the charton the left and followthese instructions:1. Find your height on the lefthandcolumn of the chart.2. Go across that row and circlethe range that your weightfalls into.3. Look to the bottom of thechart to find out what groupnumber (0, 1, 2, or 3) yourcircled weight range falls into.Write the GroupNumber(0, 1, 2, or 3) here:Write sum ofquestionsA-E (from page 1)Lastly, calculatethe sum of these 2numbers. This isyour SCREENINGSCORE:Question F2 DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED.Measure the circumference of your LEFT calf byfollowing the instructions below:1. Loop a tape measure all the way around your calf to measure its size.2. Record the measurement in cm:• If less than 31cm, enter “0” in the box to the right.• If 31cm or greater, enter “3” in the box to the right.© SIGVARIS[Write the sum of questions A-E (from page 1) here:Lastly, calculate the sum of these 2 numbers.This is your SCREENING SCORE:Screening Score (14 points maximum)12–14 points: Normal nutritional status8–11 points: At risk of malnutrition0–7 points: Malnourished Copy your SCREENING SCORE:If you score between 0-11, please take this form to a healthcareprofessional for consultation.All trademarks are owned by Société des Produits Nestlé S.A., Vevey, Switzerland.© 2012 Nestlé. All rights reserved.