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Physician/Dietitian Referral Attention ___________________________

Your patient _______________________ was recently referred to the hospital Dietitian at risk for malnutrition. In an attempt to reduce the risk of readmission for poor nutrition, please consider following up and monitoring this patient.

SGA (Subjective Global Assessment) Score:

____ B (mild/moderate malnutrition)

____ C (severe malnutrition)

Other indications of malnutrition:

____% weight loss

____ poor intake

The resources provided were:

• High energy/ high protein diet resource • Resource on grocery store delivery services • Resource on meal services available in Niagara • Transportation-Groceries/Shopping • Med Pass kit • Nutrition supplement information

Follow up needed to monitor:

____ Weight

____ Food intake

____ Food Access

____________________________ Registered Dietitian