Eating Disorders Referral Form Who is completing this form/making the referral? * REQUIREDPatient (self-referral)Patient's parentPatient's GPAnother medical professionalSomeone elseIf someone else, please give further details * REQUIRED Referrer detailsReferrer name * REQUIRED Referrer telephone number * REQUIREDReferrer email address * REQUIRED Referrer location/address * REQUIRED Patient informationFull name * REQUIRED First Last Date of birth - must be dd/mm/yyyy format * REQUIRED DD slash MM slash YYYY Contact telephone number * REQUIREDPatient's email address * REQUIRED 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’. We require the patient's email address so we ca share documents with them.I confirm the patient is happy to be contacted via email Address * REQUIRED Street Address Address Line 2 City Post Code Gender * REQUIRED NHS number Has the person being referred (or a parent if they are below age 16) consented to this referral? * REQUIRED Yes No GP name * REQUIRED GP telephone number * REQUIRED GP address * REQUIREDSchool/college name, address and telephone.If applicableHealth informationCurrent height * REQUIRED Current weight * REQUIRED ROUTINE BLOOD SCREEN TO BE UNDERTAKEN IN PRIMARY CARE AS FOLLOWS: full blood count, liver function, renal profile, including calcium, phosphate and magnesium, random glucose, ferritin, coeliac antibody screen, inflammatory markers (C reactive protein (CRP), erythrocyte sedimentation rate, plasma viscosity), thyroid function, HbA1Ct, Vitamin D, B12, folateDate last bloods taken - must be dd/mm/yyyy format * REQUIRED DD slash MM slash YYYY Reason for referral -Do you believe that your or the patient’s eating difficulty is driven by: * REQUIRED 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 healthWeight pattern over recent months * REQUIREDCurrent food intake * REQUIREDCurrent fluid intake * REQUIREDMissing meals? * REQUIRED Yes No Frequency per day/week * REQUIRED Restricting meals? * REQUIRED Yes No Frequency per day/week * REQUIRED Binge eating * REQUIRED Yes No Frequency per day/week * REQUIRED Vomiting * REQUIRED Yes No Frequency per day/week * REQUIRED Laxatives * REQUIRED Yes No Frequency per day/week * REQUIRED Diuretics / Diet Pills * REQUIRED Yes No Frequency per day/week * REQUIRED Excessive exercise * REQUIRED Yes No Frequency per day/week * REQUIRED Please give details of any substance misuse * REQUIREDHas there been any previous contact with the eating disorders service? * REQUIRED Yes No Please give details of previous eating disorders treatments * REQUIREDWhat is the current level of motivation towards treatment and change? * REQUIRED High Risk FactorsTo be completed by medical referrers onlyRisk factors - tick all that apply * REQUIRED 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.Additional documentationPlease upload any ECG, blood results or other documents below.Add files Drop files here or Select files Max. file size: 64 MB.