Nutrition and Dietetic Referral Form

CHILDREN YOUNG PEOPLE CARE GROUP

Paediatric Referral For Bridgewater Community Dietetics

Please fill out the form giving as many details as possible and ensure relevant blood test results are included. Please post / fax to Dietitians Office, Claire House, Phoenix Way, Wigan, WN3 4NW, Fax:

481173

PLEASE NOTE REFERRALS ARE ACCEPTED ONLY FOR THE CONDITIONS BELOW. IN EXCEPTIONAL CIRCUMSTANCES PLEASE CONTACT THE TEAM LEADER OR CARE GROUP MANAGER.

PATIENT DETAILS

Name of Child/Young person Safeguarding Yes No ______

Address______

Postcode: ______Daytime Tel. No: ______

Mobile Tel No ______DOB ______

GP ______Tel No: ______

Address: ______

DIAGNOSIS ______

DIAGNOSIS/REASON FOR REFERRAL – Please tick

  Tube feed patient e.g. PEG/NG/PEJ

  Paediatric faltering growth. Weight…………..kg …………(Centile)

Length/Height…..………cm.…………(Centile)

  Newly diagnosed diabetic

  Existing diabetic needing review/Recently commenced/Change of insulin

  Cystic Fibrosis

  Inflammatory Bowel Disease i.e. Crohns disease

  Coeliac

  Suspected allergy please specify ………………………………

  Diagnosed allergy______IgE mediated Skin prick ð Stool sample ð

RELEVANT DETAILS TO AID PRIORITISATION e.g. Medical History, investigations, drug therapy, social circumstances. Ethnicity? Interpreter required? Wheelchair bound?

THE PAEDIATRIC NUTRITION AND DIETETIC SERVICE MAY SEND AN APPOINTMENT REMINDER VIA THE TEXT MESSAGE SERVICE. IF YOU DO NOT WISH TO RECEIVE REMINDERS IN THIS WAY PLEASE LET US KNOW.

(PLEASE PRINT CLEARLY)

Name of referrer: ______Position: ______

Address/base ______Contact tel no. ______

Signature ______Date: ______Aug 2011