TRAFFORD SPECIALIST WEIGHT MANAGEMENT SERVICE REFERRAL FORM
                           Please complete all sections - missing information will result in the referral being delayed
Email complete forms to TSPOA1@nhs.net

•	BMI 40kg/m2  (BMI 37.5kg/m2 for patients from a BAME background)
•	Trafford resident
•	18 yrs or over
•	Those assessed as motivated to engage with a lifestyle weight management programme

REFERRAL CRITERIA:

•	People who have undergone Bariatric Surgery in the past 2 years
•	People with a diagnosed eating disorder
•	People with CKD above Stage 3
•	People requiring dietary advice specifically for the management of conditions such as IBS, allergies, gestational diabetes, poorly controlled diabetes

EXCLUSION CRITERIA:

•	Weight gain likely due to drug/medicine management
•	Alcohol or drug abuse 
•	Major mental health illness - such as psychosis, severe depression 
•	Hypothyroidism 
•	Cushing’s syndrome 

REFER ONCE STABLE:

READINESS TO CHANGE ASSESSMENT:                                                        Tick box to confirm Patient agrees referral to the Specialist Weight Management Service and understand that they must demonstrate a long-term commitment to making lifestyle changes.  	                                                                                                    
										
PATIENT DETAILS:
Surname: Surname 
	Name: Given Name 	
Home Full Address (stacked) 
	DoB: Date of Birth 	
	NHS Number: NHS Number 	
Telephone: Patient Mobile Telephone / Patient Home Telephone 	Ethnic Origin: Ethnic Origin 	
Next of Kin:
Name:      
Contact details:     
NOK relationship to patient:      	Gender:
With which gender does patient identify –
 Female, including transgender women
 Male, including transgender men
  Non-binary
  Patient prefers not to say

GP: Usual GP Full Name 
	GP Address: Organisation Full Address (single line) 	

 Client completed the Interim and returning for the Bariatric Education Course

MEDICAL INFORMATIOIN:
Weight 	Height 
	BMI 	
Relevant biochemistry, for example -

Blood Pressure 
HbA1c 
Single Code Entry: Serum cholesterol level...  
Single Code Entry: Serum high density lipoprotein cholesterol level...  
Single Code Entry: Serum low density lipoprotein cholesterol level...  
Single Code Entry: Serum triglycerides level...  
ALT 
Single Code Entry: Serum TSH (thyroid stimulating hormone) level...  

Medication 
	
Relevant medical history and diagnoses, including mental health –

Problems
Consultations 

      

ACCESS NEEDS                                                        COMMUNICATION NEEDS
Is the patient housebound and needing home visits?                                               Yes/No

Any relevant information for home visit - animals of concern, gaining access etc      
	Communication needs due to disability or sensory loss?                            Yes/No
If yes, please state…
	
	Interpreter required?              Yes/No
If yes, which language…
	
Any concerns about verbal or physical abuse from patient or relatives                  Yes/No
If yes, please give details…

PLEASE NOTE: A physiotherapy assessment is not part of the programme for every patient, and by signing this referral form you agree that the patient is not at increased medical risk from carrying out self-managed graded activity/exercise. 

REFERRER DETAILS:
Name:      
	Telephone number:      	
Designation:      
	Base:      	
DATE:      
	Short date letter merged 	
Email complete forms to TSPOA1@nhs.net