Appendix B 

Home Visitation Program Model Guide 

1. Home Visit Preparation with HDM Initial Malnutrition Assessment 

2. PowerPoint Presentation: “Guide to a Successful Nutrition Home Visit”

Home Visit Preparation 

1. Review past patient records (medical, AAA, HH) 

2. Discuss, when appropriate, with other providers 

3. Call to remind patient you are coming 

4. Review “Home Visitation” power point presentation 

Name: Assessment Date: DOB: _ Age: Sex: M/F 

Address: _apt# City: Zip: County: 

Phone: ( ) - Email: 

Referred by: 

HDM Initial Malnutrition Assessment 

Demographic/Social 

Marital status: Married ☐ Single ☐ Widowed ☐ Divorced ☐ Other ☐

Caregiver/ Contact Person: Relation: Phone: ( ) -

Household Composition: 

Alone ☐ Spouse/partner ☐ Spouse and children ☐ Child/children ☐ Relative ☐ Non-relative ☐

Other ☐

Medical benefits: 

Medicare ☐ Medicaid ☐ None ☐ Other ☐

Finances: Below national poverty level? Yes ☐ No ☐

☐ Independently manages all finances and money 

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☐ Independently manages daily purchases but needs assistance with paying bills/ banking/ large transactions 

☐ Unable to manage finances 

Currently receiving the following services: 

Food stamps ☐ Weatherization ☐ Lifeline ☐ Food Bank/Pantry ☐ Medicaid Waiver ☐

Subsidized Housing ☐ Homemaker program ☐ Veteran ☐ Spouse of Veteran ☐ Home Health Aide ☐

Nursing Speech Therapy ☐ Occupational Therapy ☐ Physical Therapy ☐ Senior Companion ☐

Other ☐

Race or ethnic background: 

Caucasian ☐ Asian, Pacific Islander ☐ African American ☐ Hispanic ☐ American Indian/native Alaskan ☐

Other ☐

Legal Guardian? Yes ☐ No ☐ Name: Phone: ( ) -

Pets? Yes ☐ No ☐ If yes describe: 

Pets provided with: Pet food ☐ Table scraps ☐ Both ☐

Perceived Wellbeing 

Would you say your physical health over the past year has: Improved ☐ Stayed same ☐ Become worse ☐

Explain why: 

Would you say your mental health or emotional state over the past year has: Improved ☐ Stayed same ☐ Become worse ☐

Explain why: 

Would you say your ability to get around and take care of yourself, and to do things for yourself and other people over the past 

year has: Improved ☐ Stayed same ☐ Become worse ☐

Explain why: 

Medical/Physical 

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Primary Doctor: Name: Phone: ( ) -

Recent hospital discharge date: Admission Diagnosis: 

History of hospitalization (past 3 years): 

Admission date: Admission Diagnosis: 

Admission date: Admission Diagnosis: 

Admission date: Admission Diagnosis: 

Current medical diagnosis: 

Self-assessed pain scale: Are you dealing with any pain? Yes ☐ No☐ Location: 

If yes rate your pain on a scale 1-10 (1 no pain, 10 worst pain) 

1 2 3 4 5 6 7 8 9 10 

Medications 

Analgesics Diuretics 

Antacids Insulin/hypoglycemic Agents 

Antibiotics H2 Blockers 

Anticoagulants Laxatives 

Anticonvulsants Lipid Lowering 

Antihypertensive Non-Steroidal 

Anti-Parkinsonian Psychotherapeutic Drugs 

Cardiac Glycosides Steroids 

Dietary Supplements/Herbals Dose 

Vitamin/Mineral 

Nutrition/Herbal Supplement 

OTC 

Additional details / notes 

(Check most appropriate box) 

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☐ Independently takes medications as prescribed (correct dose and times) 

☐ Ability to take medications independently from prefilled daily pill dispenser 

☐ Unable to take medications independently 

Risk factors for fall and injury, i.e., identify any conditions about this patient that increase his/her risk of falling or injury (check all 

that apply) 

Orthostatic hypotension ☐ osteoporosis ☐ gait problem ☐ impaired balance ☐ confusion ☐ Parkinsonism ☐

pain ☐ inadequate assistive device(s) ☐ other ☐

Additional details / notes 

History of falls, trip, and/or stumble? Yes ☐ No ☐ # in the past 6 months # GLF (explain) 

Bone fractures in the past 6 month? Yes ☐ No ☐ # in the past 6 months (explain/location) 

Sensory impairments affecting functioning (check all that apply) 

Hearing: Conversation difficulties ☐ deaf ☐ uses corrective aid ☐

Vision: Uses corrective lenses ☐ Blind ☐

Additional details / notes 

Cognitive/Behavioral 

Mini-Cognitive Test 

a. Ask patient to repeat three unrelated nouns. Then tell them you will be asking them to repeat the words later. 

b. Instruct patient to draw a clock. Have patient perform task after each instruction item. 

i. 

ii. 

iii. 

iv. 

Draw clock face 

Place numbers on face 

Place hands on clock to read 11:10 

Repeat the three nouns. 

c. Interpretation: 

i. Give one point for each recalled word after the clock draw distracter 

ii. A score of zero indicates positive screen for dementia 

iii. A score of one or two with an abnormal CDT* indicates positive screen for dementia 

iv. A score of one or two with a normal CDT* indicates negative screen for dementia 

v. A score of three indicates negative screen for dementia 

(*CDT – clock drawing test) 

Date: Score: 

d. Past Scores 

Date: Score: 

Date: Score: 

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Anxiety ☐ Yes ☐ No How long? (Days/Weeks/ Months/Years) 

Depression: ☐ Yes ☐ No How long? (Days/Weeks/Months/Years) 

Mood changes: ☐ Yes ☐ No How long? (Days/Weeks/Months/Years) 

Patient Health Questionnaire (PHQ-2): 

Over the past two weeks, how often has the patient been bothered by any of the following problems? 

e. Little interest or pleasure in doing things 

0 = not at all 

1 = several days 

2 = more than half the days 

3 = nearly every day 

f. Feeling down, depressed, or hopeless 

0 = not at all 

1 = several days 

2 = more than half the days 

3 = nearly every day 

Date: Score: 

Functional 

Shopping: 

Grocery shopping provided by: Spouse/Family ☐ Friend ☐ Other ☐

Frequency: per (Week/Month) 

Food Preparation: 

(Check most appropriate box) 

☐ Able to plan, prepare, and serve balanced meals if supplied with ingredients 

☐ Able to heat and serve pre-made meals 

☐ Unable to prepare, heat or serve meals 

Cooking Facilities (check all that apply): Stove ☐ Microwave ☐ Refrigeration ☐ Plumbing/water ☐

Kitchen stocked with adequate food preparation equipment/tools? Yes ☐No ☐

Able to independently use all food preparation equipment/tools? Yes ☐ No ☐

Kitchen is clean and tidy? Yes ☐ No ☐

Fridge is well stocked? Yes ☐ No ☐

Pantry is well stocked? Yes ☐ No ☐

Foods in kitchen are within expiration dates? Yes ☐ No ☐

Safely reaches items on low and high shelves? Yes ☐ No ☐

Meal preparation: Self (times/week ) ☐ Other person (times/week ) ☐ Nutrition services (times/week ) ☐ 

Additional details / notes 

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Home environment 

Living room: 

☐ Cluttered 

☐ Couch/chair- patient able to stand from: 

☐ Rugs 

☐ Adequate Lighting 

Bedroom: 

Patient able to get on and off of bed? Yes ☐ No ☐

Bathroom: (check all that apply) 

☐ Shower handles ☐ Hand held shower ☐ Shower chair ☐ Commode ☐ Raised toilet seat 

☐ Floor condition good ☐ Rugs ☐ Shower/ Tub ☐ Walk-in 

Additional details / notes 

Safety considerations: 

Physical Self-Maintenance Scale (PSMS) 

Activities of Daily Living 

Descending numbered items represent worsening states of function. Choose the item that best describes the resident’s functional 

status. Scores in all categories should then be totaled. The higher the final score, the greater the degree of impairment. 

A. Toileting 

1 ☐ Cares for self at toilet completely, no incontinence. 

2 ☐ Needs to be reminded or needs help in cleaning self, or has rare (weekly at most) accidents. 

3 ☐ Soiling or wetting while asleep more than once a week. 

4 ☐Soiling or wetting while awake more than once a week. 

5 ☐ No control of bowels or bladder. 

Score: 

B. Feeding 

1 ☐ Eats without assistance. 

2 ☐ Eats with minor assistance at mealtimes and/or with special preparation of food, or help in cleaning up after 

meals. 

3 ☐ Feeds self with moderate assistance and is untidy. 

4 ☐ Requires extensive assistance for all meals. 

5 ☐ Does not feed self at all and resists efforts of others to feed him/her. 

Score: 

C. Dressing 

1 ☐Dresses, undresses, and selects close from own wardrobe. 

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2 ☐ Dresses and undresses self with minor assistance. 

3 ☐ Needs moderate assistance in dressing or selection of clothes. 

4 ☐Needs major assistance in dressing, but cooperates with efforts of others to help. 

5 ☐ Completely unable to dress self and resists efforts of others to help. 

Score: 

D. Grooming 

1 ☐ Always neatly dressed, well groomed, without assistance. 

2 ☐ Grooms self adequately with occasional minor assistance, e.g., shaving. 

3 ☐ Needs moderate and regular assistance or supervision in grooming. 

4. ☐ Needs total grooming care, but remain well-groomed after help from others. 

5. ☐ Actively negates all efforts of others to maintain grooming. 

Score: 

E. Physical Ambulation 

1 ☐ Goes about grounds and surrounding area (e.g., town or city) on their own. 

2 ☐ Ambulates within residence or about one block distances. 

3 ☐ Ambulates with assistance of (check one) 

☐ Another person ☐ railing ☐ cane ☐ walker 

☐ Wheelchair – gets in and out without help 

☐ Wheelchair – needs help getting in and out 

4 ☐ Sits unsupported in chair or wheelchair, but cannot propel self without help. 

5 ☐ Bedridden more than half the time. 

Score: 

F. Bathing 

1 ☐ Bathes self (tub, shower, sponge bath) without help. 

2 ☐ Bathes self with help in getting in and out of tub. 

3 ☐ Washes face and hands only, but cannot bathe rest of body. 

4 ☐ Does not wash self but is cooperative with those who bathe him/her. 

5 ☐ Does not try to wash self, and resists efforts to keep him/her clean. 

Score: 

Total of all scores: 

The higher the final score, the greater the degree of impairment with a total score of seven representing the lowest level 

of impairment, and a total score of 30 representing the highest level of impairment. 

Additional details / notes 

Nutrition 

Weight: Height: 

(a) Any unintentional weight change in the past six months? Yes ☐ No ☐ Loss ☐ Gain ☐

(b) How much weight change? lbs/kg in the past weeks/ months 

(c) Appetite: Good ☐ Fair ☐ Poor ☐

Estimated Requirements: 

7 
Calories: - kcal/day Protein: - g/day 

Based on: - kcal/kg Based on: - g/kg 

24hr Dietary Recall 

Meal Food Item Quantity Calories Protein 

Breakfast 

AM Snack 

Lunch 

PM snack 

Dinner 

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Before Bed 

Total 

Are you following any specific diet at home? Yes ☐ No ☐ (if yes explain) 

NFPE Checklist 

Region Location Task Mild Moderate Severe 

Skin Globally • Dermatitis, rashes, petechiae, ecchymosis, 

scaliness, dryness. 

Head Hair • Touch and observe for the following: 

thinness, dullness, dryness, brittleness, 

patchy growth and easily pluck able. 

Temporalis • Palpate temporal muscles. Check for 

fullness and firmness. Observe for 

depression, hollowing. 

Eyes • Orbital pads: Gently palpate area below 

eyes. Observe for darkness, hollowness, 

and/or loose skin. 

• Observe for cracked or reddened corners 

of eyes, foamy (Bitot’s Spots) areas on 

sclera; dull, dry or rough sclera; dull, milky, 

opaque cornea. 

Mouth Have patient open mouth and shine penlight 

into oral cavity. Next, have patient stick out 

tongue. Observe: 

• Mucosa: pallor, dryness, decreased 

salivary flow, ulcerations (mucositis) 

• Tongue: magenta or beefy red color; 

smooth, slick appearance (glossitis) 

(Swallowing Impaired? Yes ☐ No ☐) 

(Chewing Impaired? Yes ☐ No ☐) 

Teeth • Observe for tooth decay, missing teeth. 

(Dentition: Teeth ☐ Edentulous ☐) 

(Dentures: Upper ☐ Lower ☐) 

Gums • Observe for sponginess, bleeding; swollen, 

red, receding gums. 

Lips • Observe for bilateral cracks at corners of 

mouth, redness (angular 

stomatitis/cheilosis). 

Upper 

Body 

Deltoid • Palpate muscles around the shoulders 

(deltoid muscles) for fullness and firmness. 

Observe for squaring of shoulders. 

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Clavicle 

• Gently palpate above and below the 

clavicle for fullness and firmness. Observe 

for prominence of clavicle. 

Ribs • Have patient sit forward and palpate ribs. 

Triceps 

Skinfold 

• Have patient bend arm at 90 degree 

angle with upper arm perpendicular to 

body; if patient unable to cooperate, 

bend elbow at 90 degrees and place 

forearm horizontally across body if 

possible; grasp upper arm midway 

between shoulder and elbow with palm 

and fingers and gradually pull skin 

away from arm with fingers while 

wiggling slightly to separate fat from 

muscle. 

Interosseous • Have patient make okay sign with 

thumb and first finger and while 

palpating interosseous muscle 

between thumb and first finger and the 

interosseous muscles between 

remaining fingers. Check for fullness 

and firmness. Observe for depression. 

• Observe fingernails for missing, 

misshapen (spoon shaped), splintered, 

transverse ridging, discoloration, 

dullness, lackluster appearance, 

mottling. 

Grip Strength 

Dominant Hand: Right ☐ Left ☐

Right Hand: Left Hand: 

Avg. Avg. 

Nutrition Diagnosis: 

Functional Deficits: 

Care Plan: 

10 
Goals: 

1) 

2) 

3) 

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Clock Drawing ID: Date: _ 

References 

1. Borson S,Scanlan JM,Chen PJ et al. The Mini-Cog as a screen for dementia: Validation in a population based 

sample. J AmGeriatr Soc 2003;51:1451-1454. 

2. Borson S,Scanlan JM, Watanabe J et al.Improving identificationof cognitive impairment in primary care. Int J 

Geriatr Psychiatry 2006;21: 349-355. 

3. Lessig M, Scanlan Jet al. Time that tells: Critical clock-drawing errors for dementia screening. Int 

Psychogeriatr. 2008 June; 20(3):459- 470. 

4. Tsoi K,Chan J et al. Cognitive tests to detect dementia: A systematic review and meta-analysis. JAMA 

Intern Med. 2015; El -E9 . 

5. McCarten J, Anderson Pet al. Screening for cognitive impairment in an elderly veteran population: 

Acceptability and results using different versions of the Mini-Cog. J Am Geriatr Soc 2011; 59: 309-213. 

6. McCarten J, Anderson Pet al.Finding dementia in primary care: The results of aclinical demonstration 

project. J Am Geriatr Soc 2012; 60: 210-217. 

7. Scanlan J & Borson S.The Mini-Cog: Receiver operating characteristics with the expert and naive raters. Int J 

Geriatr Psychiatry 2001; 16:216-222. 

Mini-Cog © S. Borson. All rights reserved. Reprinted with permission of the author solely for clinical and educational purposes. 

May not be modified or used for commercial, marketing, or research purposes without permission of the author (soob@uw.edu.) 

v.01.19.16