Description of Nursing Home
Total Number of Beds in the Home (Answer all questions)	(a)Total number of beds _______ (b)Month of ____ 2018 (e.g. Jun, Jul or Aug)
Total Number of Residents in the Home (Answer all questions)	(a)Number of residents _______ (b)Month of _____ 2018 (e.g. Jun, Jul or Aug)
Number of Dietitians(Answer where applicable only)	(a)Full-time staff of Nursing Home (e.g. 1, 2 or 3): ________ OR (b)Part-time staff of Nursing Home (e.g. 1, 2 or 3): ________ OR (c)Dietetic service bought from other hospitals/ private practices (e.g. 1, 2 or 3): ________
If Part-time dietitian or Outsourced # Dietetic Services (Answer where applicable only)	(a)Number of visits per month: _______ OR (b)Number of visits per quarter (3 months): _______ OR (c)Number of visits per half yearly (6 months): ________
Frequency of dietetic review for each tube-fed patient (Tick and answer where applicable only)	How soon is resident reviewed on admission to the Home (More than 1 answer is possible): □Automatic referral on admission with fixed review once every _____ month(s) □Automatic referral on admission but follow-ups dependent on Dietitian’s order □If Hospital Memo or Transfer Letter requested □If Doctor-in-charge in the Home requested □If Family Member(s) requested □If Nursing Staff requested as resident is eating poorly
Nutritional Screening in Nursing Home
Is nutritional screening performed for all patients?	□Yes □No
Is nutritional screening for all patients repeated?	□Yes □No if Yes, how frequent is it repeated: _________________ (e.g. once a month, once every 3 months)
Number of Speech Therapists	(a)Full-time staff of Nursing Home (e.g. 1, 2 or 3): ________ OR (b)Part-time staff of Nursing Home (e.g. 1, 2 or 3): ________ OR (c)Therapist service bought from other hospitals/ private practices (e.g. 1, 2 or 3): _______
If Part-time Speech Therapist or Outsourced# Therapy Services	(a)Number of visits per month: _______ OR (b)Number of visits per quarter (3 months): _______ OR (c)Number of visits per half yearly (6 months): ________
Prevalence and Incidence of Dysphagia (Swallowing Impairment on Modified Textured Diet)
Number of residents with dysphagia or swallowing impairment	(a)Number of residents diagnosed with dysphagia, placed on modified texture (e.g. pureed, blended, minced) diet or thickened fluids this month: ____________ (b)TOTAL number of residents diagnosed with dysphagia or who are placed on modified texture (e.g. pureed, blended, minced) diet or thickened fluids: ___________________
Prevalence and Incidence of Enteral Nutrition (ALL Types of Tubes Feeding)
Number of residents on Enteral Nutrition (Tube Feeding)	(a)Number of residents with newly inserted feeding tube this month: _______ (b)TOTAL number of residents with feeding tubes: _______
Type of Enteral Nutrition Delivery Mode
Types of Feeding Tubes (please indicate NA if there are no patients on any of types of feeding tubes)	Number of residents on (a)Nasogastric Tube (NGT): _____ (b)Nasojejunal Tube (NJT): _____ (c)Percutaneous Endoscopic Gastrostomy (PEG): _____ (d)Percutaneous Endoscopic Jejunostomy (PEJ): _____ (e)Feeding Jejunostomy (FJ): _____
How are feeds delivered (please indicate NA if there are no patients on any particular delivery method)	Number of residents on (a)Bolus feeding: _____ (b)Continuous feeding with pump: ______ (c)Continuous feeding via gravity drip: ______
# Outsourced from private sector or government hospitals.