Eating Disorders Referral Form Who is completing this form/making the referral?*Patient (self-referral)Patient's parentPatient's GPAnother medical professionalSomeone elseIf someone else, please give further details*Referrer detailsReferrer name*Referrer telephone number*Referrer location/address*Patient informationFull name* First Last Date of birth* Contact telephone number*Patient's email address* Please give the patient’s email address. This is important for if a video consultation is needed. If the patient does not have an email address, please enter ‘none’. Address* Street Address Address Line 2 City Post Code Gender*NHS numberHas the person being referred (or a parent if they are below age 16) consented to this referral?*YesNoGP name*GP telephone number*GP address* School/college name, address and telephone. If applicableHealth informationCurrent height*Current weight*ROUTINE BLOOD SCREEN TO BE UNDERTAKEN IN PRIMARY CARE AS FOLLOWS: UNDER AGE 18 - full blood count, electrolytes, liver function, renal function, including calcium, phosphate and magnesium, random glucose, iron status, coeliac antibody screen, inflammatory markers (C reactive protein (CRP), erythrocyte sedimentation rate, plasma viscosity), thyroid function. AGE 18+ - full blood count, electrolytes, liver function, renal function, including calcium, phosphate and magnesium, iron status, random glucose, inflammatory markers (C reactive protein (CRP), erythrocyte sedimentation rate, plasma viscosity), thyroid function.Date last bloods taken* Reason for referral -Do you believe that your or the patient’s eating difficulty is driven by:* Concern regarding size, shape or weight A lack of interest in food A fear of vomiting or choking or other aversive consequence The sensory characteristics of food Low appetite secondary anxiety or depression Other/none of the above Any additional concerns? Including general mental health Weight pattern over recent months* Current food intake* Current fluid intake* Missing meals?*YesNoFrequency per day/week*Restricting meals?*YesNoFrequency per day/week*Binge eating*YesNoFrequency per day/week*Vomiting*YesNoFrequency per day/week*Laxatives*YesNoFrequency per day/week*Diuretics / Diet Pills*YesNoFrequency per day/week*Excessive exercise*YesNoFrequency per day/week*Please give details of any substance misuse* Has there been any previous contact with the eating disorders service?*YesNoPlease give details of previous eating disorders treatments* What is the current level of motivation towards treatment and change?*High Risk FactorsTo be completed by medical referrers onlyRisk factors - tick all that apply* BMI <13 (adults) or <70% median BMI for age (under 18)? Recent loss of ≥1 kg for two consecutive weeks? Little or no nutrition for >5 days? Acute food refusal or 2 days in under 18s? Pulse <40? BP low with postural dizziness? Core temperature <35°C? Na <130 mmol/L? K <3.0 mmol/L? Raised transaminase? Glucose <3 mmol/L? Raised urea or creatinine? ECG: e.g. bradycardia? QTc >450 ms? No high risk factors If high risk we advise URGENT referral to the Eating Disorders Service and consideration of referral to A&E. Please feel free to consult with our Risks High in Eating Disorders (RHED) Team 01242 634242.