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.

  • 1. Weight

  • Do you know your current weight?*

  • 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. 

  • When is the most recent weight you know of?*
  • During the past two weeks my weight has:*

  • 2. Food intake

  • As compared to my normal intake, I would rate my food intake during the past month as:*
  • I am now taking:*

  • 3. Symptoms

  • I have had the following problems that have kept me from eating enough during the past two weeks (check all that apply):*

  • 4. Activities and function

  • Over the past month, I would generally rate my activity as:*

  • Universal                        

    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 https://www.prehab.nhs.scot/prehab-and-me/* or scan the QR code below to access

    • Attend a universal prehabilitation workshop at your local Maggie’s Centre https://www.maggies.org/support-information/diagnosis-and-treatment/recently-diagnosed/getting-ready-treatment/* or equivalent local organisation

    *These links may not work on a mobile device. 

    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.

  • Targeted  - refer for assessment 

    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 https://www.prehab.nhs.scot/prehab-and-me/* or scan the QR code below to access

    • Attend a universal prehabilitation workshop at your local Maggie’s Centre https://www.maggies.org/support-information/diagnosis-and-treatment/recently-diagnosed/getting-ready-treatment/* or equivalent local organisation

    *These links may not work on a mobile device. 

    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.

  • Specialist - refer for assessment

    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 https://www.prehab.nhs.scot/prehab-and-me/* or scan the QR code below to access

    • Attend a universal prehabilitation workshop at your local Maggie’s Centre https://www.maggies.org/support-information/diagnosis-and-treatment/recently-diagnosed/getting-ready-treatment/* or equivalent local organisation

    *These links may not work on a mobile device. 

    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: