Self-Referral Form - Choose to Change Maternity Weight Management Programme

Self-Referral Form-Choose to Change Maternity Weight Management Programme
Eligibility Criteria (Please complete all boxes)
Which area do you live in?
Manchester
Do you have a BMI 30+ and pregnant?
Oldham
YES / NO
Salford
Tameside and Glossop
Are you aged over 18 Years?
YES / NO
What stage is your pregnancy? (weeks)
Personal Information
Mrs/Miss/Ms/Other
First Name
Surname
NHS Number (if known)
Date of Birth (DD/MM/YYYY)
Ethnicity
Phone Number
Email Address
Address
GP and Midwife Details
GP Name
GP Practice Name and address
GP Contact Number
Midwife Name
Venue attending for antenatal appointments
Midwife Contact Number
Physical Health Data
Height
Weight
BMI (if known)
Current Medication
Are you currently on any medication?
If Yes- Please provide a list of current medications
Expected Due Date
Date of first scan
YES / NO
Clients Past History Please specify any medical or personal problems that the service may need to be aware of
Do you have any communication difficulties or
learning difficulties?
YES / NO
(If yes- please state the nature of support required)
E.g. Literacy, vision, do you require an interpreter or
struggle to fill in forms.
Please return the completed form to:
Safe Haven Fax: 01204 570 965
Post: Choose to Change, ABL Health, 71 Redgate Way, Farnworth, Bolton, BL4 0JL
If you wish to speak to a member of the Choose To Change team please telephone 01204 570 999 between 9am and 5pm
`