Referral Form

Referral Form
Please complete the form as clearly as possible to ensure there is no delay with the referral
Level 3 Adult Weight Management Specialist Service for Manchester, Oldham and Salford
Manchester
Oldham
Salford
(Please tick)
Health Professional Details
Name
Job Title
Practice / Organisation / Department Name
Address (or Practice Stamp)
Contact Number
Contact Email Address
Client Personal Information (Please complete all boxes)
Mr/Mrs/Miss/Ms/Other
First Name
Surname
NHS Number (if known)
Male / Female
Date of Birth (DD/MM/YYYY)
Ethnicity
Home Phone Number
Mobile Phone Number
Email Address
Address
GP Details (Leave blank if referred by GP and details are included at the top)
GP Name
GP Practice Name
By making this referral the client gives permission for Choose To Change to contact their GP
Client Health Data
Eligibility Criteria (Please Tick)
Client has a BMI > 35
Client has a BMI > 30 and pregnant
Client requests Bariatric Surgery and requires a minimum of 6 months lifestyle intervention
Physical Health Data
Height (m)
Weight (kg)
BMI (kg/m2)
BP (mmHg)
Current Medication Please provide a list of current medication for the client or attach a list to the referral form
Clients Past History (please tick all relevant boxes)
Type 1 diabetes
Type 2 diabetes
Ischaemic heart disease
Hypertension
Cardiomyopathy
CVA / TIA
Peripheral vascular disease
Polycystic ovarian syndrome
Obstructive sleep apnoea
Severe Dismobility
Subfertility
Back pain
Specify any other medical problems that the service may need to be aware of
Myocardial Infarction
Heart failure
Hyperlipidaemia
Joint problems
Obesity hypoventilation
Hypothyroidism
Biochemical Readings (these should ideally be dated within 6 months)
Cholesterol
HDL
LDL
Triglycerides
HBA1C
Date:
Date:
Date:
Date:
Date:
Does the patient have any learning difficulties or communication difficulties?
E.g. Literacy, vision, requires an interpreter, struggles with understanding when filling in forms.
Yes / No? If yes- please state the nature of support required
Are there any safety or security issues around this patient?
Yes / No? If yes- please state the nature of support required
Is the patient housebound? Yes / No?
All patients will be assessed medically by our team and physical activity will be tailored according to their ability.
From your personal knowledge of this patient, please outline any concerns you may have regarding their ability to
partake in any form of physical activity?
Please tick to confirm you have discussed the Choose to Change Service with the client, they understand they
must be ready to change and have agreed to be referred.
Health Professional Signature
Date
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 or email [email protected]
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