This form must be completed in full and emailed/ faxed to the following:

Email: Fax: 0208 235 4009

Please complete all sections of the form. Please note that incomplete or ineligible forms will be returned.

If you are faxing the forms please draw on the diagrams. For emailed forms please make detailed notes next to the diagrams.

Patient Information
Title: / Patient Forename: / Patient Surname:
Home Address:
Postcode: / NHS Number: / Date of Birth: / Gender: Male/ Female
Tel: / Mobile: / Email:
Patient’s present location:
1) An inpatient on ………………………………. Ward at …………………………………………….. Hospital
Hospital Swtichboard Number: …………………………………… Ward extension:……………………………..
Doctor’s Bleep Number: …………………………………………….
2)Other (please specify): …………………………………………………………………………………………….
General Practitioner Information
Name of GP: / GP Telephone number:
GP Address:
Postcode:
Referring Doctor Information
Name of Doctor Completing Form:
Name of Consultant:
Specialty: / Secretary Tel:
Referring to:Medical □ Surgical □
Named:
Reason for Referral
□ Complex access issues (inc fistuloclysis) □ Surgical re-appraisal
□ Initiation/ training of new home PN patient □ Surgical reconstruction
□ High output stoma/fistula despite standard care
□ PN with metabolic/ psychiatric co-morbidity/ complications
□ Other (describe below)
Cause of Intestinal Failure
Please include key medical and surgical events (attach additional information)
Previous Operations
Please list ALL relevant operations and attach operation notes
Date (dd/mm/yy) / Operation
Presumed Anatomy
/ Please record areas resected, length of each part of remaining SB and location of any strictures or areas of known disease eg Crohn’s
Co-morbidities
Please describe severity e.g. Echo findings, FEV1, eGFR, HbA1C
□ Cardiac …………………….. □ Respiratory ……………………□ Neurological ……………….
□ Renal/ Uro ………………… □ Hepatic ………………………..□ Endocrine ………………….
□ Psych ……………………… □ Haem inc. VTE ………………..
□ Other (use space for more detail)
Pressure Sores: ………………………………………………………………………………………….
Mobility:Bed bound □Mobilising with aid □Mobilising independently □
Please specify what aid: ……………………………………………………………………………………
Enterocutaneous Fistula (e) and Anatomy
□ From SB □ From colon □ Other (detail)Output ..……….ml/24hours
Bowel length proximal to fistula: □ Unknown Known = …………cm
□ Laparostomy wound □ Gastrostomy tube □ Persistent intra-abdominal sepsis
Current Route(s) of Nutrition
Tick all in use – please attach current PN prescription (including details of volume, N2, Glucose, Calories, Lipid, Sodium and Magnesium. Please liaise with your dietitian
□ Oral □ NG □ NJ □ Parenteral
Percutaneous: □ gastrostomy □ jejunostomy □enteroclysis
Anthropometry:
Date measured ……………… Weight ………kg Weight loss……. kg over …………
BMI: …….. Oedema □ Y □ N
Venous Access
Please liaise with your Nutrition Nurse Specialist
□CVC: Tunnelled □Y □N Cuffed □Y □N □Implanted port □PICC □None of these
Lumens 1 2 3 4 5Site (□ R □ L) (□ IJV □ SCV □ Fem)Date inserted ………………
Line tip position: ………………….Are any veins thrombosed? □N □Y Detail:……………
Investigations (all Radiology & Histology)
Please include dates and key findings
Blood Results
Date Measured: …………/…………./…………
HB / Na+ / Bili / Ca2+ / ESR
MCV / K+ / ALT / PO42+ / Ferritin
WCC / Ur / ALP / Mg2+ / B12
PLT / CR / ALB / CRP / Folate
Medications
Including anticoagulation, insulin, subcut infusions
Drug / Dose / Route / Frequency

Allergies: ………………………………………………………………………………………………………

Are there any non-clinical issues we should be aware of? …………………………………………………………………………………………………………………….

Referring Consultant

If following a period of stay at St Mark’s, this patient is unable for any medical or social reasons to return home/ into a suitable placement I agree to readmit him/ her back to this hospital

Form completed by:

Name (PRINT): ……………………………Signature:……………………….

Phone Number: …………………………..Date: ……………………………
Patient Registration Form