Simcoe County Eating Disorder Service

Simcoe County Eating Disorder Service

1

SimcoeCounty Eating Disorder Service

Referral Form:

First Name: ___Last name______D.O.B: mm/dd/yy

Referral datemm/dd/yy OHIP

Address: ______

Parent(s)/Guardian(s) Names:

Phone Numbers: (h) (w)

Who does patient reside with Both parents  Mother Father Guardians

Ward of CAS

Physician name: M.D. Phone #:

Presenting Problems: ______

______

______

History of Present Illness:

______

______

______

Prior Mental Health diagnoses and /or treatment: depression anxiety disorder□OCD □ ADHD self harm behaviorssuicidal behaviorsuicidal ideation

Bipolar Disorder history of CAS involvement □Other ______

History of abuse: sexual physical emotional

Substance abuse ETOH /other______

Past Medical History: ______

______

Allergies: ______

Current Medications (include BCP, Vitamins, Laxatives, Name/doses/frequency):

______

Sexual History: Sexual Activity Birth Control Safer Sex Practices

Age at First Sex______

Significant Family Illness:______

Family Health History:

Mother: Age _____Health ______

Ethnicity ______Employment______

Father: Age _____Health ______

Ethnicity ______Employment______

Physical Examination (in gown, no shoes):

Weight &Height:please provide a growth chart or complete growth history if available

Current Weight: Date taken: mm/dd/yy _____kg or ______lbs

Current Height: Date taken: mm/dd/yy ______cm or ____inches

Lowest PreviousWeight: Date taken: mm/dd/yy ______kg _or _____lbs

Weight loss: Yes/No Onset: mm/dd/yy Duration: ______

Precipitating Factors: ______

Weight Control methods:

Food restriction Binge Vomiting Laxatives Diet pills Exercise

Menses:  Menarche ______

Usual cycle______

Last menstrual period______

Last normal menstrual period______

Blood Pressure supine ______Blood Pressure Standing______

Heart Rate supine______Heart Rate Standing ______

Temperature: ______

Hydration: Poor fair good very good

General appearance: marked weight loss/gain/fluctuationscold intolerance fatiguedizziness syncope hot flushes sweating episodes□bruising easily

Throat /Mouth: Dental erosions dental cariesParotid enlargement

Resp:shortness of breath

CVS: History of heart problem chest painheart palpitations arrhythmias.

CNS:Memory loss □poor concentration insomnia

GI/GU:gastric discomfort early satiety delayed gastric emptying gastroesophageal refluxfrequency of BM______constipation  bleeding

Sexual Maturity Rating______

Integument- Lanugo hairhair lossskin discolorationRussell sign poor healing

Problem Summary: ______

______

______

______

Investigation: Please attach and fax a copy of blood work results and ECG

  1. Labs: Sodium, Potassium,Chloride, Glucose, BUN, Creatinine, AST, ALT, Calcium, Magnesium, Phosphorus, Albumin, Total protein, Ferritin, TSH, CBC diff., Platelets, ESR, Serum amylase, Cholesterol

LH, FSH

  1. ECG

Signature of Physician:______

Thank you for your assistance. Please completeall sections before mailing/faxing to

SimcoeCounty Eating Disorders Service

Royal Victoria Regional Health Centre

Fax: (705) 739-5631

For more information please call

(705) 728-9090, ext. 47210

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