OUTPATIENT DIETETIC REFERRAL FORM NHS Number………………………………….. Surname……………….……….Title…........... Forename……………………………………… Address…............................................................................................ Postcode…………… Telephone/mobile………….………………. Date of Birth…………………..………………. Sex: M / F Interpreter? Y / N Language?................ GP Name……………………………………… GP Practice…………………………………… Contact number………………………………. Referrers name / Profession / contact details (if different from GP) ...................................... ........................................................................ ………………………………………………….. Signature………………………………………. Date of referral…............................................ Please refer to the Primary Care Dietetic Referral Criteria before completion. Please complete ALL boxes. Incomplete referrals may be returned to reduce clinical risk. Reason for referral (please include as much relevant information as possible attaching additional information as necessary) Height Weight BMI Other relevant medical history Relevant medications Relevant biochemistry and/or investigation results for referral (see referral criteria and attach results if necessary) Is a domiciliary visit required? Y / N If Yes, please state why. ................................................................................................................................. …………………………………………………………………………………………………………………….. Please identify any potential risks when undertaking a home visit?......................................... ............................................................................................................................................ Referrals will only be accepted for clients who are truly housebound & visits will only be undertaken where absolutely necessary. Assessment, advice may be given in the first instance following a telephone . Please send referrals to Nutrition & Dietetic Outpatient Services, Level 1 Old Building, Bristol Royal Infirmary, BS2 8HW. (Fax 0117 342 3183). Any additional Information? (i.e. Learning difficulties, mental health issues, other disabilities, social history/issues) July 2012 Medical Diagnosis