Nutrition for hcps

Nutrition
This questionnaire helps check your nutrition level and overall wellbeing. It asks about areas such as your weight, appetite, symptoms and how much you are able to eat and do each day. Your answers help your healthcare team understand if you are getting the nutrition you need and if any extra support is required as part of your prehabilitation.
Please enter your email address if you would like to be sent a copy of your completed questionnaire. This information will not be stored anywhere.
example@example.com
1. Weight
Do you know your current weight?*

YesNo
Current and previous weights are required for this form to function. If you don't have that information, please contact your healthcare team for advice.
Please calculate your total weight in pounds and enter that figure where requested below. There are 14 pounds in 1 stone.
What is your current weight:*
Please enter your height if you know it:
When is the most recent weight you know of?*

About one month agoAbout six months ago
What was your weight then?*
What was your weight then?*
Calculation 1a: 1 month original weight - current weight
Calculation 2a: 1 month % weight loss
Calculation 1b: 6 months original weight - current weight
Calculation 2b: 6 months % weight loss
During the past two weeks my weight has:*

DecreasedNot changedIncreased
CalcOptionA
CalcOptionB
Box 1 score

4. Activities and function
Over the past month, I would generally rate my activity as:*

Normal with no limitationsNot my normal self, but able to be up and about with fairly normal activitiesNot feeling up to most things, but in bed or chair less than half the dayAble to do little activity and spend most of the day in bed or chairPretty much bedridden, rarely out of bed
Box 4 score

Your score is:
Thank you for completing the nutrition questionnaire.

Please make a note of your score to share with your healthcare team as instructed. Your healthcare team may contact you to discuss your score in more detail.

If you provided an email address at the start you will receive an email from 'Jotform' with a pdf of your results attached after you click the submit button below.

Your next steps:
- Visit the national prehabilitation website or scan the QR code below to access
- Attend a universal prehabilitation workshop at your local Maggie’s Centre or equivalent local organisation.
Your medical team may ask you to repeat this questionnaire in the future to see if there has been a change in your nutrition level. If you notice a change in your nutrition level or general health after completing the questionnaire please contact your medical team for advice.
Thank you for completing the nutrition questionnaire.

Please make a note of your score to share with your health professional.

If you provided an email address at the start you will receive an email from 'Jotform' with a pdf of your results attached after you click the submit button below.

Your next steps:
- Visit the national prehabilitation website or scan the QR code below to access
- Attend a universal prehabilitation workshop at your local Maggie’s Centre or equivalent local organisation.
Your medical team may ask you to repeat this questionnaire in the future to see if there has been a change in your nutrition level. If you notice a change in your nutrition level or general health after completing the questionnaire please contact your medical team for advice.
Thank you for completing the nutrition questionnaire.

Please make a note of your score to share with your healthcare team as instructed. Your healthcare team may contact you to discuss your score in more detail.

If you provided an email address at the start you will receive an email from 'Jotform' with a pdf of your results attached after you click the submit button below.

Your next steps:
- Visit the national prehabilitation website or scan the QR code below to access
- Attend a universal prehabilitation workshop at your local Maggie’s Centre or equivalent local organisation.
Your medical team may ask you to repeat this questionnaire in the future to see if there has been a change in your nutrition level. If you notice a change in your nutrition level or general health after completing the questionnaire please contact your medical team for advice.
Should be Empty:

Nutrition

1. Weight

2. Food intake

3. Symptoms

4. Activities and function