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:

FOR COMPLEX FEEDING AND NUTRITION SERVICE USE ONLY Fax completed form and attachments to: ATTN Debby S. Martins, Coordinator Date received: Complex Feeding and Nutrition Service Date reviewed:  P1  P2  P3  Booked (604) 875-3244 28/Nov/14 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

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:

FOR COMPLEX FEEDING AND NUTRITION SERVICE USE ONLY Fax completed form and attachments to: ATTN Debby S. Martins, Coordinator Date received: Complex Feeding and Nutrition Service Date reviewed:  P1  P2  P3  Booked (604) 875-3244 28/Nov/14 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

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 Date received: Complex Feeding and Nutrition Service Date reviewed:  P1  P2  P3  Booked (604) 875-3244 28/Nov/14