Patient Self-Referral to Nutrition and Dietetic Service
Before filling in this referral form please ensure you have read
‘Guidance for referrals’
.
Referrals that are filled in incorrectly will be rejected and will delay your appointment.
On receipt, referrals will be prioritised. Clients requiring a home visit will be contacted directly by a clinician.
Clients that can attend a clinic appointment will be invited to contact us to arrange an appointment.
Failure to do so will lead to discharge from our service.
Please ensure all the fields marked
*
are filled in correctly.
Please select which borough your/the patient’s GP is in
*
Haringey
Islington
Patient details
Surname
*
First name
*
Gender
*
Female
Male
Date of Birth
*
(dd/mm/yyyy)
Home Address
*
Daytime number
*
NHS No.
(if known)
Hospital No
Is an interpreter required?
*
Yes
No
How would you describe your ethnic origin
*
Next of kin
*
Home Address
*
Telephone number
*
GP details
GP Practice
*
GP Name
GP Address
*
GP Telephone number
Additional Information
We will usually contact your GP to inform them of ongoing treatment and check we are providing you with tailored advice. Please confirm your acceptance.
*
Yes
No
Reason for Dietitian appt
*
What do you expect to get out of your appointment?
*
Current Weight
*
Current Height
*
Body Mass Index (BMI)
*
BMI calculator
Can you please tell us how you heard about us?
Any medical conditions should be made known in order to ensure appropriate care. Please fill in the medical questionnaire below.
Please tick in response to ALL the conditions/statements listed:
*
Do you currently have or have you ever suffered with any of the following, if YES please give details
Allergy (clinical diagnosis)
Anorexia Nervosa
Asthma
Bulimia Nervosa
Chronic Obstructive Pulmonary Disease (COPD)
Crohn’s disease
Constipation
Diabetes
Diarrhoea
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Nausea or vomiting
Heart problems
Kidney disease
Mental Health Conditions
Sleep Apnoea
Stroke
Please record most recent blood results linked to your conditions (if known):
*
If you are referring for advice on high cholesterol, type 2 diabetes or high blood pressure you must include relevant and recent test results to support your referral.
Total cholesterol
*
HDL
*
LDL
*
Triglycerides
*
Fasting blood sugar
*
HbA1c
*
Are you on any medications?
*
Yes
No
If yes please list:
Are you able to travel to clinic?
*
Yes
No
If no, please give reason:
Name of referrer
*
Profession
*
Contact details of referrer
*
Referrer Email
*
I declare that this information is correct to the best of my knowledge