COMMUNITY NUTRITION SUPPORT TEAM (DIETETICS) – …



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

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

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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______________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

______________________________________________________________________________

__________________________________ _____________________________________________________________

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: __________________________

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