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Unanswered Questions will be Highlighted in Red.

1. Body mass index (BMI):

BMI<19 BMI 19 to <21 BMI 21 to <23 BMI>23

2. Weight loss during last 3 months

Weight loss >3kg Does not know Weight loss between 2 & 3kg No weight loss

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

Yes No

4. Mobility

Bed or chair bound Does not go out of house regularly Goes out regularly

5. Neuropsychological problems

Severe dementia or depression Mild dementia or depression No psych problems

6. Has food intake declined over the past three months due to loss of appetite (including digestive problems, chewing or swallowing difficulties)?

Severe loss of appetite Moderate loss of appetite No loss of appetite