Eating Disorder Service

EATING DISORDER SERVICE

Referral information

Date of Referral: / Diagnosis:
PERSONS DETAILS
Title: / Surname: / Forename:
DOB: / Age: / Gender: M F
Home Address including postcode:
home telephone: / Mobile Telephone:
NHS number:
MEDICAL DETAILS
GP name:
surgery address:
GP telephone no:
CARE COORDINATOR DETAILS
name / agency:
address:
telephone no:
email address:
preferred contact method and availability:
SOURCE OF REFERRAL
name / agency
referrers address:
telephone Number: / email address:
Is the client aware of this referral Y N / last contact:
Summary of presenting condition
If referral is for inpatient admission what outcomes are you expecting

CURRENT PRESENTATION

Does the person fulfil ICD 10 Criteria for either Anorexia Nervosa or Bulimia Nervosa?

(See ICD 10 Criteria for ED below)

ANOREXIA NERVOSA (ICD 10 F50.0) / Yes / No
A. There is weight loss leading to a body weight at least 15% below the normal or expected weight for age and height.
B. The weight loss is induced by avoidance of fattening foods.
C. There is a self-perception of being to fat, with an intrusive dread of fatness, which leads to a self-imposed low weight threshold.
D. A widespread endocrine disorder, involving the hypothalamic pituitary gonadol axis, is manifest in women as amenorrhoea and in men as loss of sexual interest and potency.
BULIMIA NERVOSA (ICD 10 F50.2) / Yes / No
A. There are recurrent episodes of overeating (at least twice a week over a period of 3 months) in which large amounts of food are consumed in short periods of time.
B. There is a persistent preoccupation with eating, and strong, desire, or a sense of compulsion to eat (craving)
C. The patient attempts to counteract the “fattening” effects of food by one or more of the following:-
·  Self-induced vomiting
·  Self-induced purging
·  Alternating periods of starvation
·  Use of drugs such as appetite suppressants, thyroid preparations or diuretics; when bulimia occurs in diabetic patients they may choose to neglect their insulin treatment
D. There is a self-perception of being too fat, with an intrusive dread of fatness (usually leading to being underweight).
Yes / No
Is Eating Disorder the primary diagnosis?
Current Body Mass Index
Height
Weight
Specific bloods required for patients with BMI less than 15:
FBC, U&E, Phosphate, Calcium, Magnesium, Albumin, CRP, LFT, Zinc, Copper, Selenium, Iron profile, Vitamin B12 and Folate Vitamin A&D Carotene, Vit D, TFT, Glucose / Please fax these with the referral form
Does the person show any abnormalities in chemical pathology: U&E’s, cretinine , LFT, glucose and TFT? Copies of recent lab results should be enclosed with this referral.
Latest ECG to be faxed with referral
Does the person present with unresolved alcohol/illicit substance misuse? Please specify
Does the person show any neurological issues?
If yes, please specify
Yes / No
Are the any concerns related to person’s medical condition
If yes, please specify below
Current Risk Factors
If yes, specify below
Current Treatment plan (please specify below)
Current medications
Does the person think they have an eating problem?

PSYCHIATRIC HISTORY

Yes / No
Has the person been provided with specialist Eating Disorder input before?
If yes, specify below

All inappropriate referrals will be sent back to the referrer with recommendations attached or sign posted to the appropriate agencies if not suitable for specialist services.

Please email to: or

Please fax on: 01472 302311

Office Use Only
Date received / Time Received / Checked by
If BMI is less than 15 plus any one of the other criteria this is an emergency admission and should be assessed within 48 hours
BMI<15 / YES / NO
Rapid Severe Weight Loss / YES / NO
Evidence of System Failure / YES / NO
Daily Purging / YES / NO
Electrolyte Disturbance / YES / NO
Recent Discharge from SEDU / YES / NO
Co-morbid diabetes / YES / NO
Pregnancy / YES / NO
Time Referring Team Were Contacted
Action / Arrange appointment ASAP / Discuss at clinical team meeting
Has funding been put in place from the local Commissioners? / YES / NO
Please identify the Commissioner who agreed funding: