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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______________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ October 2013 1 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 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 October 2013 2