Mmse Mna GDS PDF

Mini Nutritional Assessment MNA®
Last name: First name:

ABAOAG BENIGNA
Sex: F Age: 79 Weight, kg: 57Kg Height, cm:160.02 Date: 09/17/2020
Complete the screen by filling in the boxes with the appropriate numbers. Total the numbers for the final screening score.
Screening
A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or
swallowing difficulties?
0 = severe decrease in food intake
1 = moderate decrease in food intake
2 = no decrease in food intake 1
B Weight loss during the last 3 months

0 = weight loss greater than 3 kg (6.6 lbs)
1 = does not know
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)
3= no weight loss 3
C Mobility 0 = bed or
chair bound
1 = able to get out of bed / chair but does not go out 2 = goes out 2
D Has suffered psychological stress or acute disease in the past 3 months?

0 = yes 2 = no 0
E Neuropsychological problems 0
= severe dementia or depression
1 = mild dementia
2 = no psychological problems 2
2
F1 Body Mass Index (BMI) (weight in kg) / (height in m )
0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater 2
IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION F2.

DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED.
F2 Calf circumference (CC) in cm

0 = CC less than 31
3 = CC 31 or greater 22.9
Screening score
(max. 14 points)
12-14 points:
Normal nutritional status
8-11 points: At risk of malnutrition
0-7 points: Malnourished
Ref. Vellas B, Villars H, Abellan G, et al. Overview of the MNA® - Its History and Challenges. J Nutr Health Aging 2006;10:456-465.
Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for Undernutrition in Geriatric Practice: Developing the Short-Form Mini
Nutritional Assessment (MNA-SF). J. Geront 2001;56A: M366-377.
Guigoz Y. The Mini-Nutritional Assessment (MNA®) Review of the Literature - What does it tell us? J Nutr Health Aging 2006; 10:466-487. Kaiser
MJ, Bauer JM, Ramsch C, et al. Validation of the Mini Nutritional Assessment Short-Form (MNA®-SF): A practical tool for identification of
nutritional status. J Nutr Health Aging 2009; 13:782-788.
® Société des Produits Nestlé, S.A., Vevey, Switzerland, Trademark Owners

© Nestlé, 1994, Revision 2009. N67200 12/99 10M
For more informationwww.mna-elderly.com

Geriatric Depression Scale (Short Form)
Patient’s Name: BENIGNA ABAOAG Date: 09/20/2020
Instructions: Choose the best answer for how you felt over the past week. Note: when asking
the patient to complete the form, provide the self-rated form (included on the following page).
No. Question Answer Score
1. Are you basically satisfied with your life? YES / NO 1
2. Have you dropped many of your activities and interests? YES / NO 0
3. Do you feel that your life is empty? YES / NO 0
4. Do you often get bored? YES / NO 0
5. Are you in good spirits most of the time? YES / NO 1
6. Are you afraid that something bad is going to happen to you? YES / NO 1
7. Do you feel happy most of the time? YES / NO 1
8. Do you often feel helpless? YES / NO 0
9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 0
10. Do you feel you have more problems with memory than most people? YES / NO 0
11. Do you think it is wonderful to be alive? YES / NO 1
12. Do you feel pretty worthless the way you are now? YES / NO 0
13. Do you feel full of energy? YES / NO 1
14. Do you feel that your situation is hopeless? YES / NO 0
15. Do you think that most people are better off than you are? YES / NO 0
TOTAL 6
(Sheikh & Yesavage, 1986)
Scoring:
Answers indicating depression are in bold and italicized; score one point for each one selected. A score
of 0 to 5 is normal. A score greater than 5 suggests depression.
Sources:
• Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a
shorter version. Clin Gerontol. 1986 June;5(1/2):165-173.
• Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull. 1988;24(4):709-711.
• Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression
screening scale:
a preliminary report. J Psychiatr Res. 1982-83;17(1):37-49.
Geriatric Depression Scale (Short Form) Self-Rated

Version
Patient’s Name: BENIGNA ABAOAG Date: 09/20/2020
Instructions: Choose the best answer for how you felt over the past week.
No. Question Answer Score
1. Are you basically satisfied with your life? YES / NO 1
2. Have you dropped many of your activities and interests? YES / NO 0
3. Do you feel that your life is empty? YES / NO 0
4. Do you often get bored? YES / NO 0
5. Are you in good spirits most of the time? YES / NO 1
6. Are you afraid that something bad is going to happen to you? YES / NO 1
7. Do you feel happy most of the time? YES / NO 1
8. Do you often feel helpless? YES / NO 0
9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 0
10. Do you feel you have more problems with memory than most people? YES / NO 0
11. Do you think it is wonderful to be alive? YES / NO 1
12. Do you feel pretty worthless the way you are now? YES / NO 0
13. Do you feel full of energy? YES / NO 1
14. Do you feel that your situation is hopeless? YES / NO 0
15. Do you think that most people are better off than you are? YES / NO 0
TOTAL 6
(Sheikh & Yesavage, 1986)

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Mini Nutritional Assessment MNA®

Last name: First name:

Sex: F Age: 79 Weight, kg: 57Kg Height, cm:160.02 Date: 09/17/2020

B Weight loss during the last 3 months

D Has suffered psychological stress or acute disease in the past 3 months?

IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION F2.

F2 Calf circumference (CC) in cm

® Société des Produits Nestlé, S.A., Vevey, Switzerland, Trademark Owners

For more informationwww.mna-elderly.com

Patient’s Name: BENIGNA ABAOAG Date: 09/20/2020

No. Question Answer Score

1. Are you basically satisfied with your life? YES / NO 1

2. Have you dropped many of your activities and interests? YES / NO 0

3. Do you feel that your life is empty? YES / NO 0

4. Do you often get bored? YES / NO 0

5. Are you in good spirits most of the time? YES / NO 1

7. Do you feel happy most of the time? YES / NO 1

8. Do you often feel helpless? YES / NO 0

11. Do you think it is wonderful to be alive? YES / NO 1

13. Do you feel full of energy? YES / NO 1

14. Do you feel that your situation is hopeless? YES / NO 0

Geriatric Depression Scale (Short Form) Self-Rated

Patient’s Name: BENIGNA ABAOAG Date: 09/20/2020

No. Question Answer Score

1. Are you basically satisfied with your life? YES / NO 1

2. Have you dropped many of your activities and interests? YES / NO 0

3. Do you feel that your life is empty? YES / NO 0

4. Do you often get bored? YES / NO 0

5. Are you in good spirits most of the time? YES / NO 1

7. Do you feel happy most of the time? YES / NO 1

8. Do you often feel helpless? YES / NO 0

11. Do you think it is wonderful to be alive? YES / NO 1

13. Do you feel full of energy? YES / NO 1

14. Do you feel that your situation is hopeless? YES / NO 0

(Sheikh & Yesavage, 1986)

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