No.

RM : Berat Badan :

Nama : Tinggi Badan :

Jenis Kelamin :

Usia :

3-Minutes Nutrition Screening (3-MinNS)

Score Notrition Parameters
Unintentional Weight Nutritional Intake (past 1 week) Muscle Wastage
Loss (past 6 months) Muscle From Temple Clavicle Bone
3  >7 kg  Starvation or <1/4 of usual  Hollowing,  Protruding &
portion/meal Depression of Prominent >
 Tube Feeding Temple Muscle Clavicle Bone
<1L/day (1kcal/ml feed)
<1000 kcal/day
2  >3 to 7 kg  ¼ - <1/2 of usual  Slight  Slight Protrusion
 Yes, unsure portion/meal with no oral Depression of of Clavicle Bone
supplement Temple Muscle
 Tube Feeding
1-1.25 L/day (1 kcal/ml
feed)
1000-1250 kcal/day
1  1 to 3 kg  ½ - <3/4 of usual
 Don’t know portion/meal
 ¼- <1/2 of usual
portion/meal with oral
supplement
 Tube Feeding
>1.25-1.5 L/day (1 kcal/ml
feed)
>1250-1500 kcal/day
0  No  Normal Intake  Well defined  No Protruding
Change/Weight With ¾-1 of usual Muscle Clavicle Bone
gain/Intentional portion/meal
weight loss Tube Feeding
 <1kg >1.5 L/day (1kcal/ml feed)
>1500 kcal/day
Scoring 3 2 1 0 3 2 1 0 3 2 1 0
(Circle
one per
colum)
Total Patient is at nutritional risk if score is 3 or more
Score  Referral to Dietitian