Please check our referral criteria to ensure you are providing the necessary evidence (e.g. results of blood/diagnostic tests). Available at

COMMUNITY ADULT DIETETICS REFERRAL FORM
Please complete this form in full; incomplete referral forms will be rejected
PATIENT’S DETAILS
Title: / Forename(s): / Surname:
M F / NHS Number: / D.O.B:
Address (incl. postcode):
Daytime contact number: / Alternative contact number:
ETHNICITY
White British / Any other mixed background / Black/ Black British Caribbean
White Irish / Chinese / Black or Black British African
Any other White / Asian or Asian British Indian / Any other Black groups
Mixed:White& Black Caribbean / Asian/Asian British Bangladeshi / Any other ethnic group
Mixed: White & Black African / Asian or Asian British Pakistani / Declined to state ethnic origin
Mixed: White & Asian / Any other Asian background
NEXT OF KIN’S/CARER’S DETAILS (if applicable)
Name: / Relationship to patient:
Daytime contact number: / Alternative contact number:
GP’S DETAILS
Date of referral: / GP’s Name:
Contact number: / Fax number :
Surgery address:
NHS.net email address:
REFERRER’S DETAILS (if not GP)
Name: / Job title:
Contact number: / Fax number :
Signature: / Date of referral:
Email address (safe to send patient details):
GENERAL NEEDS OF THE PATIENT
Does this patient have any communication difficulties? No Yes , please specify:
Is an interpreter is required, what language is required?
No Yes, please specify language:
Did the patient consent to referral and assessment? Yes No, please state reason:
Are you aware of the any social issues that need to be highlighted for this referral?
No Yes, please state:
MEDICAL DETAILS OF PATIENT
Height(m): / Current Weight (kg): / BMI (kg/m2): / Weight History in the last 6 months / MUST score:
0 - 1
2 - 3
4 & above
Current Diagnosis / Past Medical History:
Not Applicable
List Current Medications or attach copy : / Relevant Biochemistry or attach copy:
Date:
Not Applicable
Diet required / Reason for referral: Tick appropriate box(es) (Please ensure the reasons meet the referral criteria. Please check referral criteria for more information)
Impaired Glucose Tolerance/Impaired Fasting Glucose Obesity
Cardiovascular Disease Nutritional support
Gastro Intestinal Problems: Crohn’s Disease Ulcerative Colitis IBS
Coeliac Disease Lactose Intolerance
Food Allergy: (e.g. milk, eggs, nuts) ……………………….
Nutritional Deficiencies: Anaemia Calcium Vitamin D Others ……….
Pregnancy with special dietary needs e.g. Vegan Weight Management
Disease state: Neurological conditions ……………… Cancer/Palliative HIV/AIDS
Special Needs e.g. Learning Difficulties (Please indicate)……………..
Additional Information: ……………………………………………………………………………………………………...
Clinic Appointment Home Visit (only if Housebound) Nursing/Residential Home
Please return this referral form to:
Email:
Fax: 0208 661 3910
Contact number: 0208 661 3908