Download document - NHS Southend CCG

MoreLife Adult
Referral Form (South Essex)
Previously Carnegie Weight Management
Patient Details
Title:
Date of birth:
First name:
Gender:
Surname:
Patient preferred contact number:
Patient
Address
Email address (this will
be the main method for
contacting the patient)
Postcode:
Does the patient speak English?
☐ Yes
☐ No
NHS Number:
Is the patient registered disabled?
☐ Yes
☐ No
☐ Male ☐ Female
If yes, please state:
Does the patient have any mobility issues or are
they housebound?
☐ Yes
☐ No
Current Medical Information
Height (m):
Weight (kg):
Blood Pressure:
Resting Heart Rate:
BMI:
Exclusion Criteria*
Can you confirm that your patient does NOT meet the following exclusion criteria:
Active Bulimia
Currently Pregnant
Active Psychosis
Diagnosed Personality Disorder
Active Substance Use Disorder (SUD) including Alcohol
Dementia
Had Bariatric Surgery in the last 12 months
Does the patient meet the EoE clinical criteria for Bariatric Surgery? (BMI>40kg/m2 PLUS
severe sleep apnoea and/or Type 2 Diabetes)
Confirm
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ No
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ Yes
Referrer
CCG use
only
* Patients found to have a score of severe anxiety/depression will be assessed on an individual basis
Referral Criteria For South Essex
One of the following three criteria must be met
A BMI of 40 kg/m2 or more
A BMI of ≥ 35 kg/m2 and obesity-related comorbidity eg Type 2 Diabetes, metabolic
syndrome, hypertension, obstructive sleep apnoea (OSA), functional disability, infertility
and depression if specialist advice is needed regarding overall patient management
A BMI of ≥ 32.5 kg/m2, type 2 diabetes and of Asian descent
(CP&R and
Southend)
Confirm
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CCG use
only
All of the criteria below must be met
Referrer
Aged 17 years or over
Registered with a Practice within South Essex, or if unregistered, residing in South Essex
Morbid or severe obesity has been present for at least four years
A commitment to change behaviours
Discussions covering understanding of the likely resulting health problems, assessment of
the individual health risks and engagement in a partnership, preferably using motivational
interviewing, to modify the risks as part of a holistic approach that includes emotional
wellbeing.
Previous attempts at weight loss including participation in a community or commercial Tier
II weight management plan
In exceptional circumstances patient with BMI < 35 kg/m2 is referred, waist circumference
and reasons for referral should be given as prior approval is required from the CCG
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(CP&R and
Southend)
Use this area to supply further information evidencing how the patient meets the above criteria if necessary:
CCG use only (Castle Point and Rochford and Southend CCGs only)
Intervention authorised by:
Name
Signature
Date
Pathology (Where available please ensure these are from the last three months)
Hb1AC
Date:
Reading:
Total Cholesterol
Date:
Reading:
Haemoglobin
Date:
Reading:
HDL
Date:
Reading:
Creatinine
Date:
Reading:
Triglycerides
Date:
Reading:
TSH
Date:
Reading:
LDL
Date:
Reading:
FT4
Date:
Reading:
ALT
Date:
Reading:
Current Medical History (within the last 6 months)
Metabolic (Select all that apply)
Cancer
☐
Mechanical (Select all that apply)
Osteoarthritis (OA)
Ischaemic Heart Disease (IHD)
Other arthritis (eg Rheumatoid etc)
Cardiomyopathy
Heart Failure
Peripheral Vascular Disease (PVD)
Myocardial Infarction (MI)
Stroke
Transient Ischaemic Attack
Hypertension
Diabetes Type 1
Diabetes Type 2
Hypothyroidism
Polycystic Ovary Syndrome (PCOS)
Hyperlipidaemia
Fatty Liver
Other
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Asthma
Obstructive Sleep Apnoea (OSA)
Mental Health (Select all that apply)
Anorexia Nervosa
Binge Eating Disorder
Bulimia Nervosa
Anxiety
Depression
Schizophrenia/other psychotic disorder
Alcoholism
Drug Abuse
Other
Other
Other
Or return to MoreLife (UK) Ltd. Churchwood Hall, Leeds Metropolitan University, Headingley Campus, Leeds, LS6 3QJ.
Email: [email protected] Please note, incomplete referral forms will be returned.
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Medication (please list current medications)
Obesity Stages: Please choose ONE of the following stages of obesity that best describes your patient
Stage 0: No Apparent Risk Factors
☐ Patient has no apparent obesity-related risk factors (e.g. blood pressure, serum lipids, fasting glucose
etc. within normal range) no physical symptoms, no psychopathology, no functional limitations and/or
impairment of well-being
Stage 1: Preclinical Risk Factors
☐ Patient has obesity-related subclinical risk factors (e.g. borderline hypertension, impaired fasting
glucose, elevated liver enzymes etc.) mild physical symptoms, mild psychopathology, mild functional
limitations and/or mild impairment of well-being
Stage 2: Established Co-Morbidity
☐ Patient has established obesity-related chronic disease (e.g. hypertension, type 2 diabetes, sleep
apnoea, osteoarthritis, PSOS, anxiety disorder etc.) moderate limitations in activities of daily living
and/or well-being
Stage 3: End-Organ Damage
☐ Patient has established end-organ damage such as myocardial infarction, heart failure, diabetic
complications, significant psychopathology, significant functional limitations and/or impairment of
well-being
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Stage 4: End-Stage
Patient has severe (potentially end-stage) disabilities from obesity-related chronic diseases, severe
disabling psychopathology, severe functional limitations and/or severe impairment of well-being
Referral Source details
Patient’s Surgery Name:
Surgery Address:
Surgery Postcode:
Surgery contact number:
Referrer’s name:
Referrer’s profession:
Referrer’s signature:
Date of referral:
(not necessary if emailed)
Please e m a i l t o m o r e l i f e @ n h s . n e t fax to 01245 396 934 o r with any supplementary patient pathology records which
need to accompany the referral form.
Or return to MoreLife (UK) Ltd. Churchwood Hall, Leeds Metropolitan University, Headingley Campus, Leeds, LS6 3QJ.
Email: [email protected] Please note, incomplete referral forms will be returned.