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Care Home Dietetics Referral Form

Please select from the following before proceeding

Start new referral
Retrieve previous referral progress

Email Address

Reference Number

Verification Code (Please enter the code emailed to you)

Please complete this form, as fully as possible, with relevant information and details to support the referral for patients who are NOT currently under the dietetic service.

Patient Details

*Patient First Name

*Patient Last Name

*Date of Birth

*NHS Number

*Address

*Nursing Home Client or Residential Home Client?

*Is this referral for yourself?

Assessor Details

*First Name

*Last Name

*Care Home Email

*Designation

*Care Home Telephone No

Current Condition

*Medical/Surgical History:

*Is patient nearing end of life?

*If the patient has been in hospital, please specify the dates in the answer field.

*Does the resident have any pressure areas and if so, where and category.

Are there any concerns with their bowels ?

*Allergies

Food intolerances

Mobility

Communication

*Current Medication (Please include name, dose and time)

Nutrition Information

*Patient height in metres

*Patient's most recent weight and include date this was taken

*Patient's weight from the last 5 months, including dates

*Most recent MUST score

MUAC if unable to weigh

Diet

*Is patient on oral nutritional supplements? If so, Name of product, how many times per day, who prescribed?

If your resident is on an oral nutritional supplement, how much of the prescribed product does he/she take?

*Where does resident eat meals ?

*Can they eat independently /what support needed ?

Feed self

Requires prompts

Requires support

Requires to be fed

*Does the resident have any behaviours during mealtimes? If so, please describe

*What is their food consistency?

If thickened liquids are required please identify level

*What interventions have been in place when first identified reduced intake and weight loss?

Attachments

Fluid and food baseline record charts to be attached (refer to the FAQs on our website for guidance)

Please upload any other information relevant for this referral. Please note we accept a maximum of 5 documents, with a maximum 5MB per document, please limit to 5MB per document.

*Document Type	*Document Name	*Upload Docs

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