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The ‘Weigh Ahead’ TIER 3 SPECIALIST WEIGHT MANAGEMENT PROGRAMME TEL: 02380 764964 FAX: 02380 512757 Email: [email protected] Please complete in the presence of the patient and ensure all areas are completed, any missing information will result in the referral being delayed. For office use only: Date Received: Date checked by GP: Triage for MH: Date cleared by MDT: SAP number: Patient Information: Name: GP information: GP Name: GP Surgery: Telephone: Fax: Medical Information: Date of Birth: NHS Number: Address: Height: Weight: BMI: Landline Number: Mobile Number: Does the Patient have the following: Blood Pressure (from within last 6 months): Yes No Details & history if available Hypertension Diabetes Dyslipidaemia metabolic syndrome Obstructive Sleep Apnoea PCOS Severe Arthritis Ischemic Heart Disease COPD Asthma IBD (Crohn’s, UC) IBS Coeliac Fibromyalgia NAFLD Other – please specify Physical Activity: Can the Patient participate in the activity element of the programme? YES NO If no, why not _______________________________________________________________________ Could a tailored programme, such as chair-based activity, be devised for your patient by our Activity Advisors? YES NO __________________________________________________________________________________ Psychological Health Screening: Please list any current/past history and severity of psychological health difficulties, and any history of aggression/ violence:________________________________________________________________________________________ ______________________________________________________________________________________________ _________________________________________________________________________________________________________ _____________________________________________________________________________________ Yes Psychological barriers to attending appointments, eg agoraphobia Current Drug / alcohol misuse No Eating Disorder Screening, please ask patient: Often Never Sometimes In the past month, have you eaten till you felt uncomfortably full but felt that you could not stop? Do you eat normally in public but excessively in secret? Do you have a feasting and fasting pattern of eating? Do you ever make yourself sick or take laxatives to control your weight? Weight Management History, please ensure the patient has completed a minimum of 2 years of any of the following: GP / Practice Nurse Advice / Weight watchers, slimming world, weight loss products, exercise on referral, Health Trainers, Dietician, orlistat YES NO Has the Patient already had Bariatric Surgery, including Obalon Balloon? YES NO Patient Commitment & Consent: Patients who meet the criteria have one opportunity to join and complete this Tier 3 Specialist Programme. Therefore, we strongly recommend you assess whether the Patient is ready & committed to embark on this 6 month programme. I, the Patient, agree to participate in The ‘Weigh Ahead’ Tier 3 weight management programme, with the goal of losing 5-10% weight loss in 6 months, and give my permission for any relevant information to be sent to the service: Patient Signature: Date: Checklist before faxing or emailing: All white areas above are completed Current medications are attached The following blood test results (from last 6 months) are attached:o o o o Lipid values Thyroid value Vitamin D status Fasting blood glucose / HbA1c Inclusion Criteria: Patient is 18 or over Patient must have a BMI ≥ 35 in the presence of diabetes and/or other significant co-morbidities i.e. cardiovascular disease or sleep apnoea OR a BMI ≥ 40 without the presence of diabetes and/or other co-morbidities. Patient must have complied with weight loss interventions at Tier 2 over a 2 year period Exclusion Criteria: • • • • • • • • • Patients must not have been enrolled on or completed the programme in the past 12 months Patients who have had a bariatric surgery Patients with serious uncontrolled disease, e.g. angina, asthma, COPD, heart failure, aortic stenosis Patients with recent complicated Myocardial infarction and/or awaiting further investigation Patients with uncontrolled arrhythmia that compromise cardiac function Patients with blood pressure at rest above 180mg Systolic, 120mg Diastolic. Patients with unstable psychiatric disorder Patients with acute infection Patients that are Pregnant The ‘Weigh Ahead’ TIER 3 SPECIALIST WEIGHT MANAGEMENT PROGRAMME TEL: 02380 764964 FAX: 02380 512757 Email: [email protected]