PLEASE COMPLETE ALL PATIENT INFORMATION SECTION & …



Referral Form for CLCH Nutrition and Dietetic ServiceREFERRAL FOR ADULT NUTRITION SUPPORT AND GASTRO PATIENTS ONLYPLEASE COMPLETE ALL PATIENT INFORMATION SECTION & RELEVANT ADDITIONAL SECTIONS EMAIL: cbo@ To confirm receipt of referral call: 020 8102 5555To speak to a Dietitian call: Tel: 020 8102 5444 *Incomplete referrals may not be accepted*CCG: Central London (Westminster) FORMCHECKBOX West London (Kensington & Chelsea and Queens Park) FORMCHECKBOX Hammersmith and Fulham FORMCHECKBOX SECTION 1: PATIENT INFORMATION and HISTORYPatient Name: Surname: Sex: Male FORMCHECKBOX Female FORMCHECKBOX DOB: NHS No: Tel: Address: Mobile: Email: Postcode: Ethnicity: Interpreter Required: Yes FORMCHECKBOX No FORMCHECKBOX Language: PAA/AHgAbQBsACAAdgBlAHIAcwBpAG8AbgA9ACIAMQAuADAAIgAgAGUAbgBjAG8AZABpAG4AZwA9

ACIAVQBUAEYALQA4ACIAIAA/AD4APAB0ACAAbQBlAHIAZwBlAD0AIgBNAGEAaQBuACAAcwBwAG8A

awBlAG4AIABsAGEAbgBnAHUAYQBnAGUAIgAgAG8AcAB0AGkAbwBuAGEAbABTAHQAYQB0AHUAcwA9

ACIAMAAiACAAcgBlAGYATgBhAG0AZQA9ACIAIgAvAD4A

ADDIN "<Main spoken language>" GP name & Practice: Is this patient: Able to attend clinic FORMCHECKBOX Transport required FORMCHECKBOX Requires home visit FORMCHECKBOX - patient MUST be housebound Does this patient have access needs? (E.g. requires letters in large print, easy read or with symbols/pictures, sign language interpreter etc.) YES FORMCHECKBOX NO FORMCHECKBOX (If yes please specify)Patient is aware and consents to this referral:YES FORMCHECKBOX NO FORMCHECKBOX Consent gained for text/voicemail to be left? YES FORMCHECKBOX NO FORMCHECKBOX Safeguarding concerns? YES FORMCHECKBOX NO FORMCHECKBOX (If yes please provide further details in social history section)Contact details for other services involved (if applicable): FORMTEXT ?????Medical History:Medication:Social History:SECTION 2: CLINICAL INFORMATION (please complete where applicable):Weight: PAA/AHgAbQBsACAAdgBlAHIAcwBpAG8AbgA9ACIAMQAuADAAIgAgAGUAbgBjAG8AZABpAG4AZwA9

ACIAVQBUAEYALQA4ACIAIAA/AD4APAB0ACAAbQBlAHIAZwBlAD0AIgBMAGEAdABlAHMAdAAgAFcA

ZQBpAGcAaAB0ACIAIABvAHAAdABpAG8AbgBhAGwAUwB0AGEAdAB1AHMAPQAiADAAIgAgAHIAZQBm

AE4AYQBtAGUAPQAiACIALwA+AA==

ADDIN "<Latest Weight>"Height: BMI: MUST Score: Other:Other: Other: SECTION 3: REASON FOR REFERRAL (when prompted provide additional details or referral will not be accepted)Referral Reason Criteria Required to Accept Referral (Please )Nutritional Support FORMCHECKBOX Underweight BMI <18.5. No Diagnosis of Eating Disorder FORMCHECKBOX BMI <20.0 and diagnosis of COPD FORMCHECKBOX Swallowing/Feeding Difficulties Attach Speech and Language Therapy report FORMCHECKBOX Oral Supplement FORMCHECKBOX Initiation assessment: ACBS indication FORMTEXT ????? FORMCHECKBOX Review: current prescription FORMTEXT ????? FORMCHECKBOX Malnutrition MUST (Malnutrition Screening Tool) Score 2 or more. Action already taken: FORMTEXT ?????Gastrointestinal Problems FORMCHECKBOX Inflammatory Bowel Disease (Crohn’s Disease, Ulcerative Colitis) faecal calprotectin testing (if IBD diagnosed) FORMCHECKBOX Diagnosed Irritable Bowel Syndrome please include a gastroenterology report or test results for: full blood count (FBC)erythrocyte sedimentation rate (ESR) or plasma viscositycreactive protein (CRP)Coeliac screening resultAllergies and Intolerances FORMCHECKBOX Coeliac Disease (diagnosed/established) Include coeliac screening results FORMCHECKBOX Lactose Intolerance (diagnosed/established) Include hydrogen breath testNutritional Deficiencies FORMCHECKBOX Anaemia Include blood test results FORMCHECKBOX Other nutritional deficiencies with a confirmed diagnosis Include blood test resultsSECTION 4: OTHER RELEVANT INFORMATION (e.g. Hospital discharge, mental health, learning disabilities, SALT, reports,)SECTION 5: REFERRER (referrals will not be accepted without a printed name and signature)Name (Printed): Signature: Profession: Date: PAA/AHgAbQBsACAAdgBlAHIAcwBpAG8AbgA9ACIAMQAuADAAIgAgAGUAbgBjAG8AZABpAG4AZwA9

ACIAVQBUAEYALQA4ACIAIAA/AD4APAB0ACAAbQBlAHIAZwBlAD0AIgBUAG8AZABhAHkAcwAgAGQA

YQB0AGUAIgAgAG8AcAB0AGkAbwBuAGEAbABTAHQAYQB0AHUAcwA9ACIAMAAiACAAcgBlAGYATgBh

AG0AZQA9ACIAIgAgAEQAYQB0AGUARgBvAHIAbQBhAHQAPQAiAGQAZAAgAE0ATQBNACAAeQB5AHkA

eQAiAC8APgA=

ADDIN "<Todays date>"Address: Tel: Fax: ................
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