Intake:
Energy Balance
Oral or Nutrition Support Intake
Fluid intake
Bioactive Substances
NI 4.3 Excessive alcohol intake
Nutrient
NI 5.1 Increased nutrient needs
NI 5.2 Evident protein energy malnutrition
NI 5.3 Inadequate protein-energy intake
NI 5.4 Decreased nutrient needs
NI 5.5 Imbalance of nutrients (specify)
Fat and Cholesterol
NI 51.1 Inadequate fat intake
NI 51.2 Excessive fat intake
NI 51.3 Inappropriate intake of food fats (specify)
Protein
NI 52.1 Inadequate protein intake
NI 52.2 Excessive protein intake
NI 52.3 Inappropriate intake of amino acids (specify)
Carbohydrate and Fiber
NI 53.1 Inadequate carbohydrate intake
NI 53.2 Excessive carbohydrate intake
NI 53.3 Inappropriate intake of types of carbohydrates (specify)
NI 53.4 Inconsistent carbohydrate intake
NI 53.5 Inadequate fiber intake
NI 53.6 Excessive fiber intake
Vitamins
NI 54.1 Inadequate vitamin intake (specify using below)
NI 54.2 Excessive vitamin intake (specify using below)
A C
Thiamin D
Riboflavin E
Niacin K
Folate Other _____
Mineral
NI 55.1 Inadequate mineral intake (specify using below)
NI 55.2 Excessive mineral intake (specify using below)
Calcium Iron
Potassium Zinc
Other ______
Clinical
Functional
NC 1.1 Swallowing difficulty
NC 1.2 Chewing difficulty
NC 1.3 Breastfeeding difficulty
NC 1.4 Altered GI function
Biochemical
NC 2.1 Impaired nutrient utilization
NC 2.2 Altered nutrition related food laboratory values
NC 2.3 Food-medication interaction
Weight
NC 3.1 Underweight
NC 3.2 Involuntary weight loss
NC 3.3 Overweight
NC 3.4 Involuntary weight gain
Behavioral/Environmental
Knowledge and beliefs
NB 1.1 Food and nutrition related knowledge deficit
NB 1.2 Harmful beliefs/attitudes about food or nutrition related topics
NB 1.3 Not ready for diet/lifestyle change
NB 1.4 Self monitoring deficit
NB 1.5 Disordered eating pattern
NB 1.6 Limited adherence to nutrition-related recommendations
NB 1.7 Undesirable food choices
Physical activity and function
NB 2.1 Physical inactivity
NB 2.2 Excessive exercise
NB 2.3 Inability or lack of desire to manage self care
NB 2.4 Impaired ability to prepare food/meals
NB 2.5 Poor nutrition quality of life
NB 2.6 Self feeding difficulty
Food Safety and Access
NB 3.1 Intake of unsafe food
NB 3.2 Limited access to food
