Diet Counseling (Medical Nutrition Therapy) Referral Form

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CKD Diet Counseling (Medical Nutrition Therapy) Referral Form
NAME
DATE OF BIRTH
MEDICAL RECORD # (IF AppLICABLE)
REASON FOR REFERRAL Medical nutrition therapy for chronic kidney disease. Specific concerns or questions:
CKD DIAGNOSTIC CODE
585.
OTHER DIAGNOSTIC CODE(S)
BLOOD pRESSURE
WEIGHT
HEIGHT
RECENT WEIGHT CHANGE?
YES
NO
AMOUNT
GAIN
LOSS
FOR DIABETICS
YEAR OF DIAGNOSIS
A1C
MONTH/YEAR
LABORATORY ASSESSMENT (most recent values)
ALBUMINURIA
NOT pRESENT
IF pRESENT, SINCE
MONTH/YEAR
UACR (Urine Albumin-to-Creatinine Ratio)
MONTH/YEAR
CREATININE
eGFR (Estimated Glomerular Filtration Rate)
MONTH/YEAR
calculate eGFR
HCO3
BUN
Ca
phos
Hgb
K
Alb
LDL
HDL
TG
ipTH
Vit D
CURRENT MEDICATIONS (or attach list)
KNOWLEDGE
DOES THE pATIENT KNOW HE/SHE HAS KIDNEY DISEASE?
YES
NO
DON’T KNOW
DOES THE pATIENT KNOW THE SEVERITY?
YES
NO
DON’T KNOW
IS THE pATIENT AWARE THAT HE/SHE MAY NEED DIALYSIS?
YES
NO
DON’T KNOW
pREVIOUS DIET COUNSELING FOR CKD?
YES
NO
DON’T KNOW
ADDITIONAL INFORMATION
ORDER:
Initial MNT and follow-up
Extension with medical justification
Diagnosis change
Change in medical condition
Annual renewal
REFERRED BY
NpI #
SIGNATURE
DATE
pHONE
FAX
EMAIL
National Kidney Disease
Education Program
This form is available online at
manage-ckd/collaborate-registered-dietician. • March 2012

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