Download community nutrition support team (dietetics) – referral form

COMMUNITY NUTRITION SUPPORT TEAM (DIETETICS) – REFERRAL FORM
Please fill out ALL parts of the form giving as many details as possible.
Failure to do so will delay referral being processed and the form being returned to you for further
information.
Please post/fax to Pauline Mitchinson - Secretary, Dietitian’s Office, Wigan Health Centre (Boston
House), Frog Lane, Wigan, WN6 7LB
Tel: 01942 482090, Fax: 01942 482272
PATIENT DETAILS
Name Mr/Mrs/Miss/Ms ________________________________ DOB__________ NHS No: _______________________
Address_________________________________________________Postcode:_____________ Tel. No: ___________
Language spoken____________________________Occupational status_____________________________________
GP _______________________________________Tel No: ___________________________ Fax: ________________
Next of Kin - Name_____________________Address__________________________________Tel:_________________
PLEASE NOTE ALL SECTIONS NEED TO BE COMPLETED IN FULL
REASON FOR REFERRAL – Please tick the boxes below
 A body mass index (BMI) of less than 18.5 kg/m ² or less
 A BMI of less than 20 kg/m ² or less and unintentional weight loss greater than 5% within the last
3-6 months
 Unintentional weight loss greater than 10% within the last 3-6 months
REASON FOR REFERRAL____________________________________________________________________
DIAGNOSIS_______________________________________________________________
CURRENT WEIGHT----------------------- LAST/USUAL WEIGHT include date-----------------------------------------------------EST. HEIGHT------------------------------------------EST. BMI = -------------------------------------use attached example sheets
IS THE PATIENT HOUSEBOUND? NO  YES  please state any information that staff should be aware of to ensure
their safety ______________________________________________________________________________________
 Tube feeding patient (please circle) Nasogastric, Gastrostomy, or Jejunostomy, other state_______________
 At risk of malnutrition and fits criteria for referral. Please note due to high demand for service we can only
accept patients who fit this criteria
Has the patient consent been gained for the referral?  Yes No please give reason______________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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RELEVANT DETAILS TO AID PRIORITISATION
Relevant Medical Information e.g. diabetes, COPD: ____________________________________________ _________
Relevant investigations and blood results______________________________________________________ _______
Medication/drug therapy: ______________________________ ____________________________________________
_______________________________________________________________________________________________
Social circumstances e.g. smoker, lives alone: _____________ ___________________________________________
Allergies/intolerances or any other information you think maybe useful _______________________________________
_______________ ________________________________________________________________________________
REFERRER’S DETAILS (must be filled in-please print clearly)
Name of referrer: _______________________________________ ________ Job Title: _______________________
Address/base ___________________________________________________________________________________
Contact Tel No: ___________________________ ___________ Fax. No: _______________________________
Signature ________________________________________
Date: __________________________
EXCLUSIONS
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Age group < 18 years
Coeliac disease
Diabetes and hyperlipodaemia
Eating disorders
Food allergy and intolerance
Over weight and obese
Patients under a gastroenterologist with primary gastro diagnosis i.e.:Pancreitis
Alcoholic liver disease
 Patients requiring weight loss advice
IF UNSURE HOW TO CALCULATE BMI.
PLEASE USE: - NHS CHOICES WEBSITE BMI CALCULATOR
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