MST Form

1

Date* This field is required.

Date

2

Fasility* This field is required.

Hospital

Klinik Kesihatan

Other

3

Patient's Name* This field is required.

First Name

Last Name

4

MRN* This field is required.

5

Gender* This field is required.

Male

Female

6

Age (years)* This field is required.

8

Question 1: Have you/the patient lost weight recently without trying?* This field is required.Applies to the last six months.If unsure, ask about things that might indicate they have lost weight e.g. clothes or rings are looser, using a different belt notch.Emphasis is on 'without trying'

No

Unsure

Yes, 1-5kg weight loss

Yes, 6-10kg weight loss

Yes, 11-15kg weight loss

Yes, >15kg weight loss

Yes, but unsure amount

9

Question 2: Have you/the client been eating poorly because of a decreased appetite?* This field is required.Applies to the last six months. For example less than ¾ of usual intake. Emphasis is on ‘eating poorly’. Most often this is due to a poor appetite, but there may be other reasons sometimes e.g. chewing/swallowing difficulties.

No

Yes

10

Total ScoreScore: 0 – 1 (Low risk of malnutrition) Score: 2 (Moderate risk of malnutrition) Score: 3 – 5 (High risk of malnutrition)