Name:…………………………
JobTitle:…………………………
Tel No:……………………………
Fax No:…………………………… / Referrer:
Address:……………………..………………………………………………
………………………………… / GP:
Name……………………..
Address:……………………………………………..
……………………………
Tel No:………………….
Fax No:………………….
Patient: NHS No:
Surname……………………………
Forename…………………………
D.O.B………. Gender:…………..
Address……………………………
…………………………………….
……………………………………..
Postcode……………………………
Phone………………………………
Mobile……………………………..
Ethnicity:…………………………. Patient under PICT Y/N
Patient under Safeguarding Y/N / Medical / Psychological History
(including relevant biochemistry etc)
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Please attach additional summary if necessary and list of all current medication. / Weight:………………
Height:………………
BMI:……………………
Details of any weight change in the last 3-6 months. …………………………………………………………………………………………………………………………………………………
Reasons for Referral:(Please tick)
Diabetes Type1 Type2
Date of Diagnosis………………..
Most Recent:
HbA1c Level:……………………
Lipid Levels:……………………….
……………………………………..…………………………………….. / Weight Management :
If BMI >39.9 or >29.9, if pregnant, consider referring to the
specialist weight management service“Choose to Change”-ABL Health.
Phone no: 01204 570965.
Nutritional Support: (Malnourished/ underweight/ unintended weight loss)
MUST Score:…………………… / Other(please state):
……………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
If Irritable Bowel Syndrome please ensure GP has screened for coeliac disease prior to referral.
Referral to Community Nutrition Service: Please complete all sections if possible.
Please ensure person is aware of the community nutrition service, and is willing and able to make dietary changes. (See our service information sheet)
Is a home visit essential? Yes/ No Has the patient agreed to the referral Yes/ No Is an interpreter/signer needed? Yes/ No If so, what Language is required ……………………………...
Are there any risks posed to staff treating this patient? Yes/ No.If so then please give details. ……………………………………………………………………………………………………………..
Are there other services involved in patients care (please give contact details)?......
……………………………………………………………………………………………………………..
If the person is in the terminal phase of illness please discuss the aims of referral with us .
Please send or fax this referral to: Central Manchester Community Nutrition Service, Levenshulme Health Centre, Dunstable St, M/C, M19 3BX Tel: 0161 861 2333 Fax:0161 248 0389