Date: DD/MM/YYYY
Patient Details / Referrer Details
Surname: / Referring GP:
Forename: / Usual GP:
Address: / Address:
Postcode: / Postcode:
Home Phone Number:
Daytime Phone Number: / Phone Number:
Date of Birth: / Fax:
NHS Number: / Signature:
Current Medical Problem, Printout Can Be Attached
Past Medical History, To Include Previous Dietetic Referrals – Printout Can Be Attached
Reason for Dietetic Referral
Please List All Current Medication Below or Attach Repeat Prescription Form

Please turn form over to complete relevant sections, as incomplete forms will be returned to referral source

Please file in the Correspondence Section of the Health Record GHNHSTFT/Y0342/12.07

Depending on the reason for referral please also complete the following relevant sections:

For Patients Referred for Weight Management, Hyperlidaemia or Diabetes

Measure / Result / Date / Measure / Result / Date
Weight (kg) without shoes / HDL Fasting Yes / No
Height (cm) without shoes / LDL
BMI / Triglyceride
HbA1c (if diabetic) / Total Cholesterol
Have they seen the practice nurse for first line advice? / % CVD Risk

For Patients Who Have Lost Weight

Measure / Result / Date / Measure / Result / Date
Usual weight (kg) / Is weight loss unintentional?
Current weight (kg) / Is the patient able to swallow?
Percentage weight loss / Is SALT involved?

For PatientsWith Anaemia

Measure / Result / Date / Measure / Result / Date
Haemoglobin / Serum B12
Ferritin / Serum Folate
Is the patient vegetarian? / Yes/No / Is patient vegan? / Yes/No

For Patients With Coeliac Disease

Measure / Result / Date / Measure / Result / Date
TTG / Patient aware of diagnosis?
Duodenal Biopsy. Please note, this must be done prior to dietary advice being given. / Patient known to gastroenterology team?

Please post or fax this completed form to:

The Department of Nutrition and Dietetics,

Cheltenham General Hospital,

Sandford Road,

Cheltenham,

Gloucestershire GL53 7AN

Tel: 0300 422 3460

Fax: 0300 422 4494

PLEASE NOTE: Incomplete forms will be returned

Please file in the correspondence section of the health record

As at 06.04.2016