REFERRAL FOR MEDICAL NUTRITION THERAPY
PHYSICIAN REFERRAL for MEDICAL NUTRITION THERAPY
To: LINDA FARR, RDN, LD, FAND
NUTRITION ASSOCIATES OF SAN ANTONIO
4414 Centerview Drive, Suite 233 San Antonio, TX 78228
Phone: (210) 735-2402 Fax: (210) 735-1176 Website:
I am referring: _____________________________________________ ______________________
Patient’s Name—Please Print Patient DOB
Patient’s Age/Sex: __________ ___________________________ _______________________________ Daytime Phone Number Alternate Phone Number
PHYSICIAN’S ORDER:
_____ RD’s Discretion _____ MD’s Diet Prescription:__________________________________________________
_____ Other Instructions: ___________________________________________________________________________
MEDICAL NECESSITY--JUSTIFICATION FOR MNT:
PRIMARY REASON:
DIAGNOSIS ICD-10 CODE DIAGNOSIS ICD-10 CODE
_____CHF _________ _____Hepatitis—_______ _________
_____Celiac Disease _________ _____Hyperlipidemia _________
_____Cirrhosis of Liver _________ _____Hypertension _________
_____Crohn’s Disease _________ _____Hypoglycemia _________
_____Diabetes—Type 1 _________ _____IBS _________
_____Diabetes—Type 2 _________ _____Impaired Fasting Glucose _________
_____Diabetes—Gestational _________ _____NASH _________
_____Eating Disorder _________ _____Obesity _________
_____End Stage Liver Disease _________ _____Overweight _________
_____Fructose Malabsorption _________ _____Pancreatitis _________
_____GERD _________ _____Other: __________________________________
_____Gout _________
OTHER COMPLICATING MEDICAL CONDITIONS:
DIAGNOSIS ICD-10 CODE DIAGNOSIS ICD-10 CODE
_____Abnormal Weight Gain _________ _____Fibromyalgia _________
_____Abnormal Loss of Weight _________ _____Gastritis _________
_____Ascites _________ _____Gluten Intolerance _________
_____Anemia _________ _____Lactose Intolerance _________
_____Anorexia _________ _____Malnutrition _________
_____Barrett’s Esophagus _________ _____PCOS _________
_____Cachexia _________ _____Sleep Apnea _________
_____Digestive/Stomach Problems _________ _____Vitamin Deficiency_____ _________
_____Esophagitis _________ _____Other:___________________________________
_____Edema _________
PERTINENT LAB VALUES: PLEASE ATTACH SHEET
EXERCISE RECOMMENDATIONS:
______ Medical Clearance for Exercise
______ Exercise Limitations: _________________________________________________________
SPECIAL INSTRUCTIONS:
This medical nutrition therapy is a necessary part of the patient’s medical treatment for the diagnoses listed above.
__________________________________________ ____________________
Physician’s Signature Date
__________________________________________________
Please Print Physician Name
................
................
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