Oral Nutritional Supplements (ONS or Sip feeds) ONS Request Form – to be completed for any prescription request All fields must be filled in. If information not available, explain why (e.g. unable to weigh)

RequestedGP: by (Name and Job Phone: PhoneFax: No. title)(Of patient) Patient’s name Patient DOB / /

Date of Patient address / / request ASSESSMENT Patient need to meet the following 3 criteria before they can be prescribed ONS Patient meets ACBS criteria: Please specify ACBS criteria below a. Short bowel syndrome b. Intractable malabsorption e.g. Malnutrition as defined by MUST c. Pre-operative preparation of patients who are malnourished d. Proven inflammatory Bowel Disease 1 e. Following a gastrectomy f. Dysphagia g. Disease related malnutrition h. Cont. ambul. peritoneal dialysis (CAPD) or Haemodialysis Malnutrition Universal Screening Tool (MUST) Please specify MUST score score calculated Malnutrition defined as one of the following: Height  BMI < 18.5kg/m2 2  > 10% Unintentional weight loss (last 3-6months) Most recent weight / Date / /  BMI < 20 AND > 5% unintentional weight loss (last 3-6 months) Or at Malnutrition Risk Most recent BMI  Little or no intake for > 5 days Poor absorptive capacity/high nutrient losses Highest weight 3-6 months Patient has tried the FOOD FIRST approach for 1-2 months with no benefits What actions have been taken: Details: 3 c Food fortification - c Extra nourishing snacks - c Extra nourishing drinks - PRESCRIPTION REQUEST Aymes Shake (1st line Powder) 388 Kcal, 15.6g Prot Only prescribe for: Fortisip Bottle(1st Line standard milkshake), 200ml, 300Kcal, 12g Prot  5 day trial Fortisip Compact(2nd Line Compact), 125ml 300Kcal, 12g Prot CHOOSE  28 days ONE: Altraplen Protein (2nd Line high Protein), 200ml, 300Kcal, 20g Prot All prescriptions Fresubin Jucy (2nd Line Juice), 200ml, 300Kcal, 8g Prot must be issued on nd Resource Fibre (2 Line High fibre), 200ml, 400Kcal, 18g Prot acute Nutritional Goals Target Review date Weight (1 month) Continue with nourishing drinks, nourishing Snacks and food fortification. Only offer ONS in-between meals and not as a meal replacement.

Produced by Surrey Heath CCG prescribing support dietitian April 2016 For review, April 2017