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Questionnaire for Enteral Nutrition (pdf) - Illinois - www2 illinois

Questionnaire for Enteral Nutrition (pdf) - Illinois - www2 illinois 2025

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The document is a questionnaire from the State of Illinois Department of Healthcare and Family Services designed for the initial certification, recertification, or change in prescription for participants requiring enteral nutrition. It collects participant information, general health conditions, details about enteral nutrition products used, clinical assessments related to oral supplements, WIC eligibility for children under five, and requires certification from a healthcare practitioner.

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What makes someone a candidate for enteral nutrition?

Enteral nutrition is indicated for patients who need nutritional supplementation and have a functioning gastrointestinal tract, but cannot swallow food safely. Feedings can be administered via enteral tubes placed into the stomach or into the small intestine (usually the jejunum).

What conditions may make enteral nutrition necessary?

Enteral tube feeding is indicated in patients who cannot maintain adequate oral intake of food or nutrition to meet their metabolic demands. Healthcare professionals commonly use enteral feeding in patients with dysphagia.

What is a nutritional assessment questionnaire?

Nutritional assessment forms are important tools used by dietitians and nutritionists to gather information about a clients nutritional status, dietary habits, lifestyle, health conditions and history, and anything related to nutrition.

Which patient would be an appropriate candidate for enteral tube feed?

Enteral nutrition is considered MEDICALLY NECESSARY under the following conditions: An anatomical inability to swallow exists, due to, for example, head and neck cancer or an obstructing tumor or stricture of the esophagus or stomach.