©2010 American Dietetic Association

Oncology Toolkit

Oncology Toolkit
Table of Contents

1. Overview of Oncology Toolkit

2. Medical Nutrition Therapy Protocol Forms for Implementing Oncology Evidence-Based Nutrition Practice
Guideline
a. Medical Nutrition Therapy Summary Page for Breast Cancer
b. Medical Nutrition Therapy Summary Page for Colorectal Cancer
c. Medical Nutrition Therapy Summary Page for Esophageal Cancer
d. Medical Nutrition Therapy Summary Page for Gastric Cancer
e. Medical Nutrition Therapy Summary Page for Head and Neck Cancer
f. Medical Nutrition Therapy Summary Page for Hematologic Malignancies
g. Medical Nutrition Therapy Summary Page for Lung Cancer
h. Medical Nutrition Therapy Summary Page for Pancreatic Cancer
i. Medical Nutrition Therapy Flowchart of Encounters for Oncology
j. Medical Nutrition Therapy Encounter Process for Oncology

3. Documentation Forms
a. Instructions for Medical Nutrition Therapy Sample Referral Form
b. Sample Referral Form: Referral for Medical Nutrition Therapy
c. Medical Nutrition Therapy Oncology Initial Progress Note
d. Medical Nutrition Therapy Oncology Follow-Up Progress Note
e. Examples of Oncology Nutrition Diagnosis PES Statements
f. Sample Initial Documentation Note: Head and Neck Cancer Case
g. Sample Follow-Up Documentation Note: Head and Neck Cancer Case

4. Outcomes Management Forms

a. Outcomes Management: Nutrition Monitoring and Evaluation
b. Outcomes Management Forms in Excel
1. Outcomes Monitoring Form
2. Sample Outcomes Monitoring
3. Aggregate Data Graphs

5. Appendices
a. Appendix 1: Table of Contents Patient Education Materials
Patient Education Materials
b. Appendix 2: Table of Contents Professional Clinical References
Professional Clinical References
c. Appendix 3: Patient Library Recommendations
d. Appendix 4: Oncology Outpatient Screening Criteria Suggestions
e. Appendix 5: Home Tube Feeding Checklist: Pump
f. Appendix 6: Home Tube Feeding Checklist: Gravity Drip
g. Appendix 7: Feeding Tube Schedule
h. Appendix 8: Head and Neck Cancer Survivors Diet Resources
i. Appendix 9: Nutrient Table
j. Appendix 10: The Cancer Survivorship Care Plan
Survivorship Care Plan Summary Forms:
a) Breast Cancer
b) Colorectal Cancer
c) Esophageal Cancer
d) Gastric Cancer
e) Head and Neck Cancer
f) Hematologic Malignancies
g) Prostate Cancer
 ©2010 American Dietetic Association Oncology Toolkit
MNT Summary Page for Oncology Nutrition: Pancreatic Cancer

Medical Nutrition Therapy Summary Page for Oncology Nutrition:

Pancreatic Cancer

Setting: Ambulatory Care or adapted for other health care settings (Adult 18 years old or older)
Goal: Supportive MNT to prevent treatment interruptions
Encounter Length of contact Time between encounters
1 30-45 minutes Initial
2 or more 15-30 minutes Ongoing as needed

Outcome Assessment Factors Expected Outcomes of Ideal/Goal Value of MNT

MNT
Summary of Oncology Nutrition Evidence-based Recommendations
Biochemical Data and Anthropometric Measurements
Height, weight, BMI
usual weight,
percent weight loss

See ON Toolkit: Appendix 2: Patient is able to state the importance of For all patients: Minimize weight loss during cancer
Professional Clinical maintaining adequate hydration during treatment.
References: chemotherapy.
Cancer and Nutrition
Screening section: "ADA
Pocket Guide to Nutrition
Assessment";
"Nutrition Screening,
Triage...."
Karnofsky Score section

Determining energy needs:

Resting metabolic rate (RMR)
via Indirect Calorimetry or
using HBE equation with
actual body weight, adjusted
for physical activity level
Labs
(As determined by co-morbid
conditions, such as HgA1C
for DM, thyroid panel for
hypothyroidism, etc.; check
glucose levels if patient is on
steroids).

See ON Toolkit Appendix 2:

Professional Clinical
References:
Assessment section:
"ADA Pocket Guide to
Nutrition Assessment"

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 ©2010 American Dietetic Association Oncology Toolkit
MNT Summary Page for Oncology Nutrition: Pancreatic Cancer

Food or Nutrient Delivery

Food Variety and Energy
Intake
Patient is able to tolerate foods during Ideal Goals:
See ON Toolkit: Appendix 2: chemotherapy Adequate calorie intake to maintain weight
Professional Clinical Reference
Cancer and Nutrition-Specific Patient or caregiver is able to select Adequate protein intake.
section: nutrient-rich food sources with medical
Clinical Guide to Oncology food supplement or enteral nutrition.
Nutrition, 2nd edition, p. 100-104
Management of Nutrition Impac
Symptoms in
Cancer and Education
Handouts;
Recipes section
See ON Toolkit: Appendix 3:
Patient Library
Recommendations:
Treatment-Related Cookbook
list
Fluid intake

See ON Toolkit: Appendix 1: Patient is able to state reason for Patient drinks adequate amounts of total fluids
Patient Education Materials: maintaining adequate hydration during daily to keep saliva thin and to prevent dehydration
Fluids and Dehydration cancer treatment
section Patient is able to avoid emergency intravenous
Patient or caregiver is able to identify signs hydration
See ON Toolkit: Appendix 2: and symptoms of dehydration
Professional Clinical Patient is able to avoid interruption of planned
References: Patient is able to state the daily goal of treatment schedule.
Management of Nutrition drinking at least 48-64 fluid ounces daily
Impact Symptoms in Cancer
and Education Handouts Patient is able to state the reason for
drinking more fluids if experiencing
diarrhea

Patient can name several sources of

fluids currently available at home.

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 ©2010 American Dietetic Association Oncology Toolkit
MNT Summary Page for Oncology Nutrition: Pancreatic Cancer

Enteral and Parenteral

Nutrition Patient or caregiver is able to select Patient is able to tolerate medical food
See ON Toolkit: Appendix 2: nutrient-rich food sources with medical supplements
Professional Clinical Reference food supplement or enteral nutrition
Cancer and Nutrition Ideal Goals:
Screening section; Patient is able to select medical liquid Adequate calorie intake to maintain weight
"ADA Pocket Guide to supplements or snacks to support food Adequate protein intake.
Nutrition Assessment"; intake
"Nutrition Screening, Patient or caregiver is able to experience a smooth
Triage...." ; Arrangements are made for timely delivery initiation of enteral feeding start-up, including
Karnofsky score section of enteral nutrition supplies delivery of supplies and patient education on the
Enteral Feedings section: use and care of the feeding tube
"ADA Pocket Guide to EN", Arrangements are made for the patient or
"Physical Signs Suggestive of caregivers to receive education on the Patient is able to maintain weight weekly during
...." care and use of the feeding tube treatment

Patient or caregiver is able to follow a tube Patient is able to maintain adequate hydration
feeding schedule weekly during treatment.

Patient is able to tolerate tube feedings Patient is able to follow the “Tube Feeding
and method of feeding (syringe, gravity- Schedule
drip feeding bag and pump)
Patient or caregiver reports being able to achieve
Patient or caregiver is able to state the goal rate for enteral feedings
amount and purpose of water flushes.
Patient is not placed at risk for food-borne illness

Patient or caregiver reports no problems with

diarrhea, constipation, regurgitation, bloating,
nausea or vomiting

Patient or caregiver is able to maintain patency of

the feeding tube.

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 ©2010 American Dietetic Association Oncology Toolkit
MNT Summary Page for Oncology Nutrition: Pancreatic Cancer

Texture modification
See ON Toolkit: Appendix 1: Patient or caregiver is able to identify Patient or caregiver is able to modify food textures
Patient Education Materials: foods well tolerated to promote comfortable food intake.
Eating Tips section;
Recipes section Patient or caregiver is able to change the
texture of food, if experiencing sore throat,
See ON Toolkit: Appendix 2: duodenal stents, bowel constrictions or
Professional Clinical mouth sores.
References:
Cancer and Nutrition-Specific
section:
Management of Nutrition
Impact Symptoms in Cancer
and Education Handouts,
“Possible Bowel
Obstruction”;
Recipes section.

Food preparation

See ON Toolkit: Appendix 1: Patient or caregiver is able to state various Patient or caregiver is able to use cooking
Patient Education Materials: quick and simple cooking methods which techniques to minimize fatigue
Blenderized Diet section; can be used to minimize fatigue
Recipe section; Food Safety Patient or caregiver is able to prepare
section Patient or caregiver is able to use a meals that are well-tolerated
blender for food preparation if needed.
See ON Toolkit: Appendix 2: Patient is not placed at risk for food-borne illness.
Professional Clinical Patient or caregiver is able to identify safe
References: food handling, preparation and storage
Cancer and Nutrition-Specific practices.
section:
Management of Nutrition
Impact Symptoms in Cancer
and Education Handouts

See ON Toolkit: Appendix 3:

Patient Library
Recommendations:
Treatment-Related Cookbook
list

PEARL # 1
If a patient has financial
issues or lives alone with no
caregiver, refer patient to
the Social Worker for
assistance.

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 ©2010 American Dietetic Association Oncology Toolkit
MNT Summary Page for Oncology Nutrition: Pancreatic Cancer

Eating frequency and

pattern
Patient is able to eat five to six small meals Patient tolerates foods eaten.
See ON Toolkit: Appendix 2: or snacks per day, including breakfast. Ideal: Adequate calorie intake to maintain weight
Professional Clinical
References: Pancreatic Patient is able to eat adequate amounts of protein.
Cancer section

Vitamin or mineral intake

See ON Toolkit: Appendix 2: Maintains dietary reference intake of Patient with multiple food allergies, or
Professional Clinical vitamins and minerals intolerances may require the use of dietary
References: supplements (e.g., calcium, vitamin D for
Assessment section; If patient is experiencing steatorrhea, lactose intolerance)
Cancer and Nutrition-Specific water-miscible vitamins may be used to
section: meet the dietary reference intake of Patient has no Clinical symptoms of
Clinical Guide to Oncology vitamin and minerals. vitamin/mineral deficiency.
Nutrition, 2nd edition, p.100-104.
Dietary Reference Database
section
Drug Information Database
section
See ON Toolkit Appendix 8:
“Dietary Reference Intake...”

Use of dietary
supplements
Use of oral omega-3 fatty acid:
See ON Toolkit: Appendix 2: Intake of omega-3 fatty acid as a medical Patient practices safe use related to dietary
Professional Clinical food supplement or oral supplement is not supplements.
References: recommended:
Cancer and Nutrition-Specific
section: To alter prolonged acute phase
Clinical Guide to Oncology response (Evidence: Fair)
nd
Nutrition, 2 edition, p.100-104
Dietary Supplement Databases Or for anti-cachectic effects
section; (Evidence: Strong)
Bariatric surgery section
(gastric bypass); Patient understands risks and benefits
Gastric Cancer section (post- dietary supplements.
gastrectomy or total
gastrectomy);
Integrative Therapies section;
Pancreatic Cancer section
(pancreatic enzymes and
steatorrhea management)

See ON Toolkit Appendix 8:

“Dietary Reference Intake....”

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 ©2010 American Dietetic Association Oncology Toolkit
MNT Summary Page for Oncology Nutrition: Pancreatic Cancer

Medication use
Patient is able to take medications Patient experiences no undesirable food
See ON Toolkit: Appendix 2: properly to achieve maximum symptom or drug interaction
Professional References: relief. (E.g. nausea, diarrhea.)
Cancer and Nutrition-Specific Patient or caregiver can describe
section: Clinical Guide to symptoms of pancreatic enzyme
Oncology Nutrition, 2nd edition, insufficiency.
p.100-104; Chapter 15;
Chemo-Therapy section; If patient is experiencing steatorrhea, Patient tolerates meals with use of pancreatic
Drug Information Database pancreatic enzymes and water-soluble enzyme replacement
section; Pancreatic Cancer vitamins may be used
section Patient or caregiver is able to use all medications
Patient or caregiver is able to adjust the appropriately and as indicated.
PEARL # 2 use of pancreatic enzymes appropriately
Encourage the patient to and as indicated with each meal and
report ineffectiveness of snack
any medications used for
symptom management. Patient or caregiver is able to identify
potential food/drug interactions

Patient or caregiver is able to alter

medication administration schedule to
avoid food or drug interactions.

Behavioral/Environmental
Physical activity
Patient is able to participate with limited Ideal: No change in PG-SGA, activities and
See ON Toolkit: Appendix 2: physical activity with assistance, such as functional level during treatment.
Professional Clinical activities of daily living during treatment.
References:
Cancer and Nutrition
Screening section;
Karnofsky Score section

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MNT Summary Page for Oncology Nutrition: Pancreatic Cancer

Nutrition Counseling
Behavior therapy
Patient or caregiver can alter food Patient or caregiver is able to locate recipes and
See ON Toolkit: Appendix 2: choices when experiencing difficulty resources for use, when nutrition impact symptoms
Professional Clinical References: eating due to nausea, diarrhea or cause difficulty eating during treatment.
Integrative Therapies section; constipation.
Recipes section

PEARL #3
(Concept of “Food is Medicine”
and changing one’s attitude
about eating.) Regardless of
the ‘taste’ of any food you try
to eat, your body needs the
nourishment from foods.
Eating is an important part of
your treatment in which you
have the control. Think of your
food as your “medicine”. Your
body needs it and do not let its
“taste” prevent you from
eating. Most medicines are not
made only to ‘taste good’.

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Name:____________________ MR# _____ ©2010 American Dietetic Association
Oncology Toolkit

Medical Nutrition Therapy Oncology Initial Progress Note

Name: _____________MR# _______ DOB: ________Referring physician: _______________ Date: _______
Age:______ Ethnicity: ____ Spoken language:____________Written language:_____________
Medical Dx: __________________________ Time: start: ________ end:_________ total:_____
Type of treatment: Chemotherapy regimen:___________________________ Frequency: _______________________
Radiation: ____________________ Goal of cancer treatment: ___Curative ____Palliative
Nutrition Assessment
Patient states (chief complaint):

Anthropometric Measurements: Ht._____ Wt._________Usual weight________ BMI ______

Weight History (collect weekly weights for all medical diagnoses):

Weight Date

√ SYMPTOM: ASSESS:
anorexia early satiety/nausea/depression/taste difficulties
diarrhea consistency of stools, # watery stools/day)
vomiting anti-nausea meds, freq of use vs. instruction label
hyperglycemia steroid- induced, other medications
nausea triggers, onset, duration
dysphagia solid foods vs. beverages, swallow evaluation assessment completed?
constipation diet history, fiber content, dietary fiber supplements, adequate fluid intake, medications
esophagitis radiation treatment field—head/neck, mediastinal nodes, center of chest
heartburn GERD/overeating/tumor pressure/size of meals, frequency of meals, position after eating
stomatitis/mucositis cause; current medications for pain control
taste changes onset, seasonal allergies/ sinus problems, hx alcoholism—possible zinc deficiency
weight loss Usual weight Current weight Calculate % usual weight
xerostomia/ consistency of saliva, fluid intake, oral thrush, oral hygiene
dry mouth

Medical Health History:

If PEG tube placed, indicate date: Pre-treatment (circle): Y N
Pertinent surgeries (include date):
Name:____________________ MR# _____ ©2010 American Dietetic Association
Oncology Toolkit

Biochemical Data and Risk Assessment: Medications:

Date:_________ Name/Company Amount/Day Purpose
Labs/Tests/ Procedures Value

Dietary Supplement Use:

Name/Company Amount/Day Greater than UL (Y/N) Purpose

Client History/Food Access:

ˆLives alone ˆLives with family ˆLives at SNF ˆAssisted Living ˆOther(specify)______________
Who: Shops for groceries___________________ Prepares meals__________________ Fills prescriptions___________________

Are there financial difficulties purchasing food?

Personal History (occupation/physical activity level, exercise):

Nutrition-focused Physical Findings (dental status, muscle mass, ascites, functional activity):

Baseline for Outcomes Monitoring

Food and Nutrition History:

Nutritional Needs:
Estimated Needs Method Used

Total Energy Expenditure (TEE)_____________ ˆ Indirect Calorimetry

(RMR x Physical Activity Level) ˆ Predictive Equation: Harris- Benedict ____________________
ˆ Other _____________________
Protein ________g ˆ g/kg/day
ˆ Other ____________________
Fluid ________ml ˆ ml/kg/day
ˆ Other ____________________
Name:____________________ MR# _____ ©2010 American Dietetic Association
Oncology Toolkit

Food/Nutrient Intake (oral, enteral or parenteral) and Patient Behaviors

Calorie intake: Amount______kcal Inadequate______ Adequate______ Excessive______
Protein intake: Amount______g Inadequate______ Adequate______ Excessive______
Fluid intake: Amount______ml Inadequate______ Adequate______ Excessive______
% fat intake: Amount______% Inadequate______ Adequate______ Excessive______
Y N
Uses medical food supplements: Name:__________________ Amount:___________ml Calories:_____kcal
Protein:_____g Fluid:_____ml Fiber:______g
Cooking techniques to minimize fatigue
Currently modifying food textures
Able to maintain usual physical activity

Nutrition Quality of Life: Tool used________ Score (include total possible)______

Additional Pertinent Information:

Nutrition Diagnosis (select priority nutrition diagnoses):

Intake
ˆ Inadequate energy intake ˆ Inadequate bioactive substance intake
ˆ Excessive intake ˆ Excessive bioactive substance intake
ˆ Inadequate oral food or beverage intake ˆ Increased nutrient needs
ˆ Excessive oral food/beverage intake ˆ Evident protein-energy malnutrition
ˆ Inadequate intake from enteral nutrition (EN) or parenteral ˆ Inadequate protein-energy intake
nutrition (PN) infusion ˆ Imbalance of nutrients
ˆ Excessive intake from EN or PN infusion ˆ Excessive fiber intake
ˆ Inappropriate infusion of EN or PN infusion ˆ Inadequate vitamin intake
ˆ Inadequate fluid intake ˆ Excessive vitamin intake
ˆ Excessive fluid intake
Clinical
ˆ Swallowing difficulty ˆ Food-medication interaction
ˆ Biting/chewing (masticatory) difficulty ˆ Underweight
ˆ Altered GI function ˆ Involuntary weight loss
ˆ Impaired nutrient utilization ˆ Overweight/obesity
ˆ Altered nutrition-related laboratory values ˆ Involuntary weight gain
Behavioral-Environmental
ˆ Food and nutrition-related knowledge deficit ˆ Limited adherence to nutrition-related recommendations
ˆ Harmful beliefs/attitudes about food- or nutrition-related topics ˆ Physical inactivity
ˆ Not ready for diet/lifestyle change ˆ Impaired ability to prepare foods/meals
ˆ Limited access to foods
Nutrition Diagnosis Statements (Nutrition Diagnosis, Related To (Etiology) As Evidenced By (Signs/Symptoms):

Nutrition Prescription (include nutrition needs, education, counseling, coordination of care):

Name:____________________ MR# _____ ©2010 American Dietetic Association
Oncology Toolkit

Nutrition Interventions
Meal and Snacks: Vitamin and Mineral Supplements:
ˆ General/healthful diet_______________________ ˆ Multivitamin/mineral
ˆ Modify distribution, type or amount of food and nutrients within ˆ Multi-trace elements
meals or at specified time_ ________________________________ ˆ Vitamin ________________________
ˆ Specific foods/beverages or groups_______________________ ˆ Mineral_________________________
ˆ Other:____________________
Enteral Nutrition (EN) and Parenteral Nutrition (PN) Goal/Expected Outcome:
ˆ Initiate EN or PN
ˆ Modify rate, concentration, composition or schedule (ND-2.2)
ˆ Discontinue EN or PN
ˆ Insert enteral feeding tube
ˆ Site care
Goal/Expected Outcome:

Medical Food Supplements (Type): Nutrition-related Medication Management:

ˆ Commercial beverage_______________ ˆ Initiate_______________________________
ˆ Commercial food__________________ ˆ Dose change__________________________
ˆ Modified beverage_________________ ˆ Form change__________________________
ˆ Modified food_____________________ ˆ Route change__________________________
ˆ Purpose__________________________ ˆ Administration schedule:___________________________
Goal/Expected Outcome: ˆ Discontinue_____________________________
Goal/Expected Outcome:

Initial/Brief Nutrition Education: Nutrition Counseling:

ˆ Purpose of nutrition education ˆ Theoretical basis/approach
ˆ Priority modifications: _______________________________________
Survival information ______________________________________________________________
ˆ Other:__________________________________________ ˆ Strategy
Goal/Expected Outcome: Goal/Expected Outcome:

Comprehensive Nutrition Education: Coordination of Other Care During Nutrition Care:

ˆ Purpose of the nutrition education_________________________ ˆ Team meeting________________________________________
ˆ Recommended modifications ˆ Referral to RD with different expertise_____________________
__________________________________________________________ ˆ Collaboration/referral to other providers (Cancer Center social worker,
_________________________________________________________ Onc. MD, swallow eval, etc.)____________________
ˆ Advanced or related topics ˆ Referral to community agencies/program (Meals On Wheels, food bank,
__________________________________________________________ American Cancer Society programs, Oley Foundation)
ˆ Result ___________________
interpretation___________________________________________ Goal/Expected Outcome:
ˆ Skill development
______________________________________________________
ˆ Other:________________________________________________
Goal/Expected Outcome:
Discharge & Transfer of Nutrition Care to New Setting or Provider
ˆCollaboration/referral to other providers
ˆReferral to community agencies/programs (Durable Medical Equipment
provider, home care services, etc.)

Goal/Expected Outcome:
Name:____________________ MR# _____ ©2010 American Dietetic Association
Oncology Toolkit

Monitoring and Evaluation (follow-up plan)

Food/Nutrition-related History Outcomes
Food and Nutrient Intake: Medication and Herbal Supplement Use: Factors Affecting Access to Food and
ˆ Caregiver/companion ˆ Medications, specify prescription or OTC Supplies:
ˆ Total energy intake ˆ Herbal/complimentary products ˆ Eligibility for government programs
ˆ Oral fluid amounts ˆ Misuse of medication ˆ Participation in government programs
ˆ Liquid meal replacement or Knowledge/Beliefs/Attitudes ˆ Eligibility for community programs
supplement ˆ Conflict with personal/family value system ˆ Participation in community programs
ˆ Amount of food ˆ Distorted body image ˆ Availability of shopping facilities
ˆ Types of food/meals ˆ End-of-life decisions ˆ Procurement, identification of safe food
ˆ Meal/snack pattern ˆ Motivation ˆ Appropriate meal preparation facilities
ˆ Food variety ˆ Pre-occupation with food ˆ Availability of safe food storage
ˆ Alcohol drink size/volume ˆ Pre-occupation with weight ˆ Appropriate storage technique
ˆ Alcohol frequency ˆ Readiness to change nutrition-related behaviors ˆ Availability of potable water
ˆ Pattern of alcohol ˆ Self-efficacy ˆ Appropriate water decontamination
consumption ˆ Self-talk/cognitions ˆ Access to food and nutrition-related
ˆ Total fat ˆ Unrealistic nutrition-related goals supplies
ˆ Total protein ˆ Unscientific beliefs/attitudes ˆ Access to assistive eating devices
ˆ Total carbohydrate Behavior: ˆ Access to assistive food preparation
ˆ Source of carbohydrate ˆ Nutrition visit attendance ˆ Devices
ˆ Total fiber ˆ Ability to recall nutrition goals Physical Activity and Function:
ˆ Soluble fiber ˆ Self-monitoring at agreed upon rate ˆ Physical ability to complete tasks for
ˆ Insoluble fiber ˆ Self-management as agreed upon meal preparation
Enteral and Parenteral Nutrition ˆ Avoidance ˆ Physical ability to self-feed
Intake: ˆ Restrictive eating ˆ Receives assistance with intake
ˆ Access ˆ Cause of avoidance behavior ˆ Ability to use adaptive eating devices
ˆ Formula/solution ˆ Binge-eating behavior ˆ Cognitive ability to complete tasks for
ˆ Discontinuation ˆ Purging behavior meal preparation
ˆ Initiation ˆ Meal duration ˆ Remembers to eat, recalls eating
ˆ Rate/schedule ˆ Percent of meal time spent eating ˆ Nutrition-related activities of daily living
Vitamin intake: ˆ Preference to drink rather than eat (ADL) score
ˆ D ˆ Refusal to eat/chew ˆ Nutrition-related instrumental activities of
ˆ B6 ˆ Spitting food out daily living (IADL) score
ˆ B12 ˆ Rumination ˆ Consistency
ˆ Multivitamin ˆ Patient/client/caregiver fatigue during feeding process resulting ˆ Frequency/duration
ˆ Other___________________ in inadequate intake ˆ Intensity
Mineral/element intake: ˆ Willingness to try new foods ˆ Type of physical activity
ˆ Calcium ˆ Limited number of accepted foods ˆ Strength
ˆ Iron ˆ Rigid sensory preferences ˆ TV/screen time
ˆ Other(specify)_____________ ˆ Ability to build and utilize social network ˆ Other sedentary time
ˆ Other (anorexia) ˆ Involuntary physical movement
ˆ Other____________________ ˆ Nutrition quality of life responses
Biochemical Data, Medical Tests and Procedure Outcomes
ˆ BUN ˆ Amylase ˆ Methylmalonic acid, serum
ˆ Creatinine ˆ Lipase ˆ Folate, serum
ˆ BUN:creatinine ratio ˆ Glucose, fasting ˆ Homocysteine, serum
ˆ Glomerular fi ltration rate ˆ Glucose, casual ˆ Ferritin, serum
ˆ Sodium ˆ HgbA1c ˆ Iron, serum
ˆ Chloride ˆ Pre-prandial capillary plasma glucose ˆ Total iron-binding capacity
ˆ Potassium ˆ Peak post-prandial capillary plasma glucose ˆ Transferrin saturation
ˆ Magnesium ˆ Glucose tolerance test ˆ Albumin
ˆ Calcium, serum ˆ Cholesterol, serum ˆ Prealbumin
ˆ Calcium, ionized ˆ Cholesterol, HDL ˆ Transferrin
ˆ Phosphorus ˆ Cholesterol, LDL ˆ Urine osmolality
ˆ Serum osmolality ˆ Cholesterol, non-HDL ˆ Urine specific gravity
ˆ Parathyroid hormone ˆ Total cholesterol:HDL cholesterol ˆ Other (hypoglycemia)
ˆ Triene:Tetraene ratio ˆ LDL:HDL ˆ Other_______________________
ˆ Alkaline phophatase ˆ Triglycerides, serum
ˆ Alanine aminotransferase, ˆ RQ
ALT ˆ Copper, serum or plasma
ˆ Aspartate aminotransferase, ˆ Iodine, urinary excretion
AST ˆ Zinc, serum or plasma
ˆ Gamma glutamyl transferase, ˆ Hemoglobin
GGT ˆ Hematocrit
ˆ Gastric residual volume ˆ Mean corpuscular volume
ˆ Bilirubin, total ˆ Red blood cell folate
ˆ Ammonia, serum ˆ Red cell distribution width
ˆ Prothrombin time, PT ˆ B12, serum
ˆ Partial thromboplastin time,
PTT
ˆ INR (ratio)
ˆ Fecal fat
Name:____________________ MR# _____ ©2010 American Dietetic Association
Oncology Toolkit

Anthropometric Outcomes
ˆ Height
ˆ Weight
ˆ Frame size
ˆ Weight change
ˆ Body mass index
ˆ Body compartment estimation
Nutrition-focused Physical Findings Outcomes
ˆ Digestive system (diarrhea, vomiting, nausea, constipation, heartburn, esophagitis, taste changes, stomatitis, dysphagia)
specify__________________________________________________________________________________________
ˆ Extremities, muscles and bones ___________________________________

Next Visit: ____________________ RD Signature:________________________________________________

List materials provided below (see ON Toolkit Appendix Patient Education Materials):
Example: ˆ
ˆ Changes in Taste & Smell

ˆ ˆ

ˆ ˆ