Mini Nutritional Assessment - Short Form (MNA-SF)

First Name *

Last Name *

DOB: *

Gender *

MaleFemaleOther

Name of clinician

Please start typing the name of the Doctor or Nurse Practitioner

Are you able to check BMI?

Weight *Enter the weight in kg

Height *Enter height in cm

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 intake1 = moderate decrease in food intake2 = no decrease in food intake

Weight loss during the last 3 months? *

0 = weight loss greater than 3 kg1 = does not know2 = weight loss between 1 and 3 kg3 = no weight loss

Mobility *

0 = bed or chair bound1 = able to get out of bed / chair but does not go out 2 = goes out

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

YesNo

Neuropsychological problems *

0 = severe dementia or depression1 = mild dementia2 = no psychological problems

BMI

BMI Score

0 = BMI less than 191 = BMI 19 to less than 212 = BMI 21 to less than 233 = BMI 23 or greater

Calf circumference (CC) in cm *

0 = CC less than 313 = CC 31 or greater

Health Impact: Low

(0-10)

Smoking cessation, preventive care, and reduced exposure to exacerbation risk factors; consider LAMA and rescue inhalers

Health Impact: Medium

Score: 11-20

Smoking cessation, preventive care, reduced exposure to exacerbation risk factors, and LAMA and rescue inhalers; consider ICS and/or LABA, referrals for pulmonary rehab, and possible lung transplant evaluation

Health Impact: High

Score: 21-30

Smoking cessation, preventive care, reduced exposure to exacerbation risk factors, ICS/LABA/LAMA therapy, referrals for pulmonary rehab, possible lung transplant evaluation, and O₂ supplementation

Health Impact: Very High

Score: 31-40

Smoking cessation, preventive care, reduced exposure to exacerbation risk factors, ICS/LABA/LAMA therapy, referrals for pulmonary rehab, possible lung transplant evaluation, and O₂ supplementation

P.W. Jones, G. Harding, P. Berry, I. Wiklund, W-H. Chen and N. Kline Leidy. Development and first validation of the COPD Assessment Test. Eur Respir J 2009, 34: 648–654.