Dietetic Referral Form Please note: All fields are mandatory and must be completed. Resident's First Name Resident's Last Name DOB JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031 2000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901 Nursing Home Unit (if applicable) County —Please choose an option—CarlowCavanClareCorkDonegalDublinGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperaryWaterfordWestmeathWexfordWicklow Reason For Referral (P1) MUST +2(P1) Nutrition support for wound healing(P1) Enteral feeding(P1) On Oral Nutritional Supplements but never reviewed by the dietitian(P1) Updated fluid recommendations by SALT (only if on oral nutritional supplements)(P2) Other - Please specify other reason in the box below Please refer to the Nualtra Dietetic Referral Criteria for further details Please note: the decision to open a duty of care following referral lies with the dietitian. An explanation will be given for any referral not accepted. Height (m) Weight (kg) Last month's weight (kg) Weight 3 months ago (kg) Weight 6 months ago (kg) BMI MUST 0123456 Diagnosis and Medical History Current clinical status StableInfection/Acute disease Mobility level Fully mobileWalking with assistance/aidChair/bed bound Bloods: include recent relevant blood results e.g. eGFR if resident has CKD/blood sugars if Diabetic Skin integrity Skin intactRednessPressure ulcer Bowels Opening regularlyConstipatedDiarrhoea Hydration status Good fluid intakeReduced fluid intakeFluid restricted Current tolerance of ONS: Tolerating wellVariable toleranceRefusing Current relevant medications Dietary requirements NoneLactose intolerantDiabeticAllergyCoeliac Disease (Gluten free)NPOPEG fedHigh protein high calorieReligious/cultural preferenceDietary restrictions Dietary requirements additional information Diet Texture —Please choose an option—RG7 – Regular Diet (Level 7)EC7 – Regular – Easy Chew (Level 7)SB6 – Soft & Bite-Sized (Level 6)MM5 – Minced & Moist (Level 5)PU4 – Pureed (Level 4)LQ3 – Liquidised (Level 3)Nil per Oral Fluid Consistency —Please choose an option—TN0 – Thin (Free Fluids)ST1 – Slightly Thick (Level 1 Fluids)MT2 – Mildly Thick (Level 2 Fluids)MO3 – Moderately Thick (Level 3 Fluids)EX4 – Extremely Thick (Level 4 Fluids)Nil per Oral Typical food and fluid intake: Level of assistance with feeding: IndependentAssistedFull assistance Referrer's Name Referrer's Job Title Email Address Phone Number Attachment (e.g. Food record chart/medication list) Date Consent Please select as appropriate The resident has consented to this referralThe referral has been made in the resident’s best interests Has this person been seen by the dietitian before? YesNo I can confirm I have read and implemented the appropriate care plan if applicable e.g below. Malnutrition Care Plan, Nutrition Wound Healing Care Plan, Healthy Eating Care Plan. Note: if you don't receive a confirmation email please contact your Nualtra account manager Referring nurse must sign referral with his/her name- any referrals signed as ‘CNM Nurse on duty’/‘Staff Nurse on Duty’ or left blank will not be accepted
