Division of Gastroenterology, Hepatology, and Nutrition

Complex Feeding and Nutrition Service

Division of Gastroenterology, Hepatology, and Nutrition

BC Children’s Hospital

Room K4-190 4480 Oak Street

Vancouver, BC V6H 3V4

Phone: (604) 875-2345, local 7464

INCLUDE ALL APPLICABLE AND RELEVANT REPORTS, SUCH AS GROWTH CHARTS

INCOMPLETE REFERRALS WILL NOT BE PROCESSED

Referral date: //

URGENCY / STEPS TO FEEDING TUBE TRANSITION CLINIC
Urgent / Not urgent / Assess for Steps to Feeding Tube Transition Clinic
CLIENT INFORMATION
Surname: / First Name: / Middle Name:
PHN: / DOB: / Gender: F M
Address: / Unit #:
City: / Province: / Postal code:
Home #: / Cell #: / Email:
Spoken languages: English Other: / Interpreter required: Y N
Client and family aware of the referral: Y N
REFERRING PHYSICIAN / NURSE PRACTITIONER
Name: / Agency: / Billing #:
Office #: / Fax #: / Email:
Signature:
REASON FOR REFERRAL
Consult only
Provide continuing care
MEDICAL INFORMATION
Primary diagnosis:
Other medical conditions:
MEDICAL CONCERNS
No concerns / Clinical deterioration / Food allergies / intolerances
GERD / frequent spit-ups or emesis / arching with meals / crying with meals
Constipation or diarrhea / Frequent respiratory illness
Other / comments:
FEEDING AND NUTRITION INFORMATION
(current diet order, feeding methods, …)
Feeding method: Oral NG NJ G tube GJ tube J tube
Other / comments:
GROWTH AND NUTRITIONAL CONCERNS – should first be assessed by a local dietitian
No concerns / Poor weight gain or weight loss / Feeding intolerance
Followed by local dietitian / Excessive weight gain / Poor appetite or refusal to eat
No known local dietitian / Inappropriate diet for age / Food group restrictions
Other / comments:
FEEDING CONCERNS – should first be assessed by a local feeding therapist
No concerns / Confirmed impaired swallow / Oral aversions
Followed by local feeding therapist / Choking or coughing with meals / Gagging or emesis with meals
No known local feeding therapist / Wet voice with meals / Texture restrictions
Oral-motor difficulties / Behavioral concerns
Other / comments:
SOCIAL INFORMATION
No concerns / Family distress / Financial concerns
Followed by local social worker / Child protection concerns / Child in foster care
Other / comments:
MEDICAL SUPPORT / NAME OR AGENCY
Physician / pediatrician
Gastroenterologist / ( not involved)
Dietitian / ( not involved)
Occupational therapist / ( not involved)
SLP / ( not involved)
Social worker / ( not involved)
Other:
FEEDING SUPPORT / APPROVED / PENDING / DECLINED
BCCH Feeding and Swallowing clinic
Sunny Hill Feeding Resource Team
Infant Development Program
Child Development Center
Center for Ability
Surrey Memorial Hospital Feeding Team
Other:
FINANCIAL SUPPORT / APPROVED / PENDING / DECLINED
At Home Program
BC Home Enteral Nutrition Program
Variety
Other:
ADDITIONAL INFORMATION OR CONCERNS
FOR COMPLEX FEEDING AND NUTRITION SERVICE USE ONLY / Fax completed form and attachments to:
ATTN Debby S. Martins, Coordinator
Complex Feeding and Nutrition Service
(604) 875-3244
Date received:
Date reviewed: / m P1 m P2 m P3 / m Booked
28/Nov/14