Wirral CT Paediatric Nutrition & Dietetics Referral Form
Fax return: 0151 488 7728 or Email us on
Date Of Referral: / *Referral may not be accepted if incompleteParent Consent gained for referral? / YES / NO
Patient Details / GP Details
Family name / GP practice name
Forename / GP Name
NHS Number / Work no
Gender / Fax no
Permanent Address / GP address
Postcode / Postcode
Ethnicity / Email
D.O.B / Referrer Details (if different GP)
Parent/Carers Name / Name
Relationship to child / Profession
Home tel / Tel no.
Mobile no / Fax Number
Email / Address
School/Children’s centre
Interpreter required? / YES / NO
(If Yes) Please state language required
Safeguarding concerns? / YES / NO
If yes please select below and provide further details in medical/social history section;
Child protection plan / Complex social needs
Child in need plan / Complex medical needs
CAF Completed / Looked after child (LAC)
Please list any potential risk factors that may impact on staff safety.
Contact details for other services involved (please provide name and contact details where known)
Health Visitor / Name / N°.
School Nurse / Name / N°.
Social Services / Name / N°.
CAHMS / Name / N°.
Acute Health Care Professional / Name / N°.
Speech And Language Therapist / Name / N°.
Other (please / Name / N°.
Medications
Relevant Medical / Social History
Clinical Information (please add more than one measurement if available)
Date of measurement / Weight (kg) + centile / Length / Height (cm) + centile
Reason for Referral: (child must reside or have GP in Wirral) Please tick appropriate box and provide any further information to enable referrals to be prioritized appropriately.
Faltering Growth Please enclose copy of recent growth chart. / 2+ centiles difference between weight and height/length on repeated measurements
Weight crossing 2 or more centiles
Weight/Length < 0.4th centile
Food Allergy / Delayed non IgE mediated Allergic symptoms to know food allergens see NICE CG116
Child on a prescribed infant formula.
Please state name of formula
Feeding difficulties (sensory/physical/behavioural) / Feeding difficulties in association with a clinical diagnosis and/or faltering growth
Gastrointestinal / Constipation – chronic for greater than 6 months with no known medical cause
Diarrhoea – persistent with no known medical cause
Nutritional Deficiencies
(referral to be supported with blood test or medical report) / Iron deficiency anaemia
Other (Please state)
Nutrition Support / Enteral Tube Feeding
On oral nutritional supplement e.g. Paediasure, Fortini
Name Of feed/supplement / 1. / 2
3. / 4.
Amount prescribed/day / 1. / 2.
3. / 4.
Breastfeeding / BF care plan increasing maternal milk supply commenced
(Date) / /
Weights
KG / Date
Prior to commencing plan
Post commencing plan
Peer Support involved / Yes / No
Any Further information to assist triage.
Hospital discharge summary/GP medical history attached (if relevant)
Signed by: / Date:
Ph: 0151 604 7271