Care Home To Dietetics Referral Step 1 of 9 - Referral 0% URLThis field is for validation purposes and should be left unchanged.Has the service user given consent to be referred?(Required)We cannot accept any referrals without patient consent Yes No Resident lacks capacity, referred in best interests Referral detailsDate of referral(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Care home(Required)Name of referrer(Required) Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Last Referrer's job title(Required)Resident's name(Required) Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Last Residents date of birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS number(Required)Resident's GP practice(Required)Ashville primary care centreBrierly medical centreBurleigh medical centreCaxton House surgeryDarton health centreDearne Valley group practiceDodworth medical centreDove Valley practiceDr Mellor & partnersGrimethorpe practiceHighgate surgeryHill Brow surgeryHolly green practiceHoyland medical practiceHuddersfield road surgeryKingswell surgeryLakeside surgeryLundwood medical centreLundwood surgeryMonk Bretton health centrePenistone group practiceRoyston group practiceRoyston highstreet surgerySt Georges medical centreThe Goldthorpe centreThe Grove medical practiceThe Kakoty practiceThe Rose Tree practiceVictoria medical centreWalderslade surgeryWombwell medical centreWombwell practice ChapelfieldWoodland drive medical centreResident's GP name(Required) Prefix DrDr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Last Reason for referral(Required) Red on Malnutrition Triangle: MUST of 2 or more for 2 consecutive months and resident’s weight has decreased Resident is exempt from the Malnutrition Triangle (i.e. due to dysphagia and has been recommended level 2 thickened fluids or resident has CKD stage 3B upwards) Other Reason for referral - otherAny other information, please provide as much detail as possibleCan you provide a MAR chart for the resident?(Required) Yes No Upload the resident's MAR chartIf the patient is being referred for nutrition support following the Malnutrition Triangle, please provide evidence that fortified food, nourishing snacks and nourishing drinks have been offered in line with the pathway. Max. file size: 5 MB. If you are unable to attach this to the form, please email us via a secure email address to barnsley.dietetics@swyt.nhs.uk. Please note if we do not received these documents within 48 hours the referral may be rejected/returnedIf you cannot provide a MAR chart please state why.(Required) Current state of healthDoes the resident have any of the following conditions? None Diabetes Respiratory condition e.g. COPD Coronary heart disease Dementia Cancer Stroke Progressive neurological disorder e.g. MS, MND, Parkinson’s disease Other Which type of diabetes does the resident have?(Required) Type 1 Type 2 Site of cancer(Required)Date of stroke(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Other(Required)Please provide detailsIs the resident currently suffering from depression? No Yes Gut problem other(Required)Is the resident currently suffering from any gut problem?(Required) None Constipation Diarrhoea Nausea Vomiting Other Has any medication been prescribed for this gut problem?(Required) No Yes Name of medication(s)(Required)Does the resident currently have a pressure ulcer(Required) No Yes Category of pressure ulcer(Required)Is the resident currently bed/chair bound?(Required) No Yes Is the resident currently drowsy for much of the day?(Required) No Yes What is the resident’s usual state of health?(Required) Stable Deteriorating Palliative What is the resident’s current state of health?(Required) Stable Deteriorating Palliative Please consider referral to palliative care team if symptom management support is required Has the resident been ill/unwell recently?(Required) No Yes Between which dates was the resident unwell?(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please provide more details regarding this period of illness(Required)When did the resident last see their GP or when was the GP last contacted about the resident?DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What did the GP advise? CommunicationDoes the resident find it difficult to communicate?(Required) No Hard of hearing Unable to understand speech Speech impaired or hard to understand Unable to speak Unable to communicate by other means Is the resident already known to Speech and Language Therapy because of communication difficulties? No Yes Swallowing difficultiesHas the resident been advised by Speech and Language Therapy to follow a modified texture diet and/or fluids?(Required) No Yes Modified texture diet recommendationsLevel 3 LiquidisedLevel 4 PureedLevel 5 Minced and moistLevel 6 Soft and bite sizedLevel 7 Easy to chewModified texture fluid recommendations:Level 0 ThinLevel 1 Slightly thickLevel 2 Mildly thickLevel 3 Moderately thickLevel 4 Extremely thickWhy does the resident have a modified texture diet?(Required) SLT advice (swallowing difficulty) Resident requested it Other Has the resident had any chest infections recently?(Required) No Yes What were the date(s) of these?(Required)FromTo Add RemoveDoes the resident ever drool or are they unable to manage their own saliva? No Yes Does the resident have difficulty swallowing medication (tablets/liquids)? No Yes Does the resident ever show any signs of having a swallowing problem(Required)Coughing or choking during or after eating or drinking; wet or ‘gurgly’ sounding voice after eating or drinking)? No Yes Please ensure referral to Speech and Language Therapy has been completed How often does this happen? At every meal/drink At least once per day At least once per week Less often Does the resident have their own teeth? No Yes Does the resident wear dentures?(Required) No Yes Do the resident's dentures fit properly? No Yes Do the residents teeth, dentures or gums mean they are:(Required) Able to chew most foods Able to chew some foods Not able to chew What condition is the resident’s mouth in?(Required) Good Sore Thrush Ulcerated Dry Please seek GP advice for appropriate treatment Eating - Help and environmentDoes the resident need different (adapted) tableware to be able to eat?(Required) No Yes Does the resident need help to be able to eat(Required) No Yes Where does the resident eat their meals?(Required) In the dining room In their own room Other Is there anything about this environment which might put them off eating?(Required) No Other residents Distractions such as television or loud radio/music Other Is the resident able to sit upright to eat?(Required) No Yes Weight and MUSTCurrent height, weight and BMIHeight (cm)Weight (kg)This field is hidden when viewing the formHeight sqBMIBMI BMI has not been calculated for this resident Weight/MUST scoreDo you know the resident's MUST score?(Required) No Yes What is the resident’s MUST score?(Required)01234 or moreHow often is the resident weighed?(Required) Weekly Fortnightly Monthly Less often Unable to weigh What was the most recent MUAC measurement?What was the date of the most recent MUAC measurement?DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Can you provide the weight chart for the resident?(Required) No Yes File(Required)Max. file size: 256 MB. Weight and height recordPlease enter at least one weight per month for the last 6 months (if known)Weight (kg)DateBMI Add RemoveIf unable to provide a full weight history, please state whyHas the resident lost weight?(Required) No Yes Did anything happen at the time of weight loss?(Required) No apparent change in medical condition Hospital admission Chest infection/UTI Vomiting/diarrhoea Low mood Other Was any new medication prescribed at the time of weight loss?(Required) No Yes Name of medication(s)(Required)Does the resident currently have oedema?Fluid swelling in legs/feet No Yes Does the resident take diuretics (water tablets) for this oedema? No Yes Has this dose/medication recently been changed? No Yes Did the resident recently have oedema which has now gone? No Yes Current food and fluid intakeCan you provide food charts for the resident?(Required) No Yes Upload electronic food chart(Required) Drop files here or Select files Max. file size: 256 MB. If you are unable to attach this to the form, please email us via a secure email address to barnsley.dietetics@swyt.nhs.uk. Please note: if we do not receive these documents within 48 hours, the referral may be rejected or returned. If you cannot provide food charts please state why(Required)What are the resident’s usual eating habits?(Required)How do they eat when they are well? Eats all meals and snacks Eats more than half of all meals and snacks Eats less than half of all meals and snacks Eats very little What are the resident’s usual eating habits?(Required)How are they eating at the moment? Eats more than half of all meals and snacks Eats less than half of all meals and snacks Eats very little On average how much fluid does the resident drink every day?(Required) Less than 500ml 500-1000ml 1000-1500ml 1500-2000ml More than 2000ml Please state any additional information regarding resident’s fluid intakeE.g. preferencesPlease list any food allergies which the resident has Add RemoveStaff Actions Add as many as applicable: Please include all relevant details to support the referral. What are staff doing to help improve residents food intake? Keeping detailed food charts to assess resident's current food intake Encouraging food and fluids little and often Encouraging nourishing drinks Encouraging nourishing snacks Fortifying food Giving prescribed nutrional supplements No action currently being taken For what length of time has this been tried?(Required) A few days 1 - 2 weeks 1 month or less Longer than 1 month Please note: if a food first approach is appropriate for this patient and has not been initiated, this referral may be rejected. Nutritional Supplements (Homemade and Prescribed)Is the resident being offered nourishing drinks?(Required) No Yes How many per day have been prescribed and are given?(Required) Once per day Twice per day 3 times per day More than 3 times per day How much of these does the resident take each day?(Required) None 1/4 1/2 3/4 All How long has the resident been having these?(Required) Days Weeks Months Years Is the resident is being offered a prescribed supplement drink?(Required) No Yes Prescribed supplementsSupplementVolume prescribed (ml)Number of times per dayVolume taken per day Add RemoveHow long has the resident been having these?(Required) Days Weeks Months Years How did the prescription start?(Required) Following a hospital admission Commenced by GP Recommended by Dietitian Already prescribed these when moved in to the home Other Food chart confirmation Please note: it is essential that a food chart is provided as part of this referral. If a copy of the resident's food chart is not supplied, we will be unable to complete the referral process and the referral may be rejected. Please confirm a copy of the food chart has been supplied alongside this submission either by uploading to the form or sent by secure email to barnsley.dietetics@swyt.nhs.uk. Confirmation(Required) I confirm a copy of the resident's food chart has been supplied alongside this submission either by uploading to the form or via secure emailCAPTCHA Page last updated on: 10th July 2025