Adult Eating Disorders Referral Form

Patient InformationTitle:

Name:

      NHS Number:           

Date of Birth:       Gender: Male FemaleAddress       Tel Home:      

Tel Work:      Post Code:       Tel Mobile:      

Marital Status:(Please mark appropriate box)

Divorced/Partnership dissolved Not Disclosed Dependent Children Married/Civil partnership Separated (Pls state age)

Widowed/Surviving partner Single

Referrer DetailsName/Phone No. of referrer:

     

Practice name and address/Phone No:

     

Registered GP:      

Referral DetailsIs the patient aware of the referral Yes No

Does patient give consent to us checking their results on SystmOne Yes No

Date of referral:      

Date Patient last seen:      

Referral priority: Routine Referral

Urgent Referral

Background information/reason for referral (to include medical and psychiatric history)

     

Eating Disorder SymptomsBody Mass Index (BMI)       kg/m² BMI date       Weight:      kg Height:       m

Previous weights: Date       Weight:      kg Date       Weight:      kg

Restricted food intake Duration:      

Restricted fluid intake Duration:      

Amenorrhoea Duration:      

Binge eating (minimum 2 episodes per week)* Number of occasions per week:      

Self-induced vomiting Number of occasions per week:      

Diuretic / Diet Pills / Laxative abuse Type / Quantity:      Number of occasions per week:      

Excessive exercise Hours per week:      

Distorted body image* eating in a discrete period of time (e.g. any 2 hour period) an amount of food that is definitely larger than most people would eat during a similar period of time in similar circumstances. Accompanied by a sense of lack of control during the episode (e.g. feeling that one cannot prevent the episode from occurring or stop it once started)

Significant Eating Disorder Risk FactorsRapid weight loss (0.5kg per week or more) Details:      

Impaired squat test(uses arms to balance, uses arms for leverage, unable to complete)

Details:      

Abnormal blood results Details:      

Abnormal ECG Details:      

Cardiovascular complications(palpitations, chest pain, cold peripheries, muscle cramp, oedema, dizziness, fainting)

Details:      

Respiratory complications(breathlessness)

Details:      

Diabetic Details:      

Pregnant / New baby Details:      

Outcome of Investigations(please attach blood results)(please complete including

Please complete investigations within a week of referral. DO NOT DELAY SENDING REFERRAL, PLEASE EMAIL RESULTS AS SOON AS AVAILABLE.

Pulse:       BP:       Temperature:      

Full blood count:       Urea & Electrolytes:       Magnesium:      Calcium profile:       Phosphate:       Glucose:      Liver Function Test:       Thyroid Function Test:      

Psychiatric RiskDeliberate self-harm: Details:      

Suicidal ideation: Details:      

Violence / harm to others: Details:      

Risk Management Plan:(e.g. if suicidal ideation is present, please state how the risk is currently managed)

     

Current Medication:     

Allergies:      

Other professionals involved in the patient’s care:     

Other relevant information:     

Signed:       Date:      

Please send to: Adult Eating Disorder Service, Box 175, Addenbrookes Hospital, Cambridge, CB2 0QQTelephone: (01223) 596201 Email: aedsadmin@nhs.net