LOGO/Ref Number

REFERRAL FORM

NEW TIER 2 & TIER 3 WEIGHT MANAGEMENT PROGRAMME – 2 YEAR PILOT Send to Single Point of Access (SPA) via email : [email protected] General enquiries Telephone: 020 3049 5242

Two new WEIGHT MANAGEMENT programmes for Southwark residents [or those registered with a Southwark GP] who are motivated to and able to commit to regular attendance at group based meetings and follow up.

Patient motivation - readiness to change

Only individuals who are motivated to change will be accepted into the service. Please assess their initial motivation with these 4 quick questions. The table below shows how the answers will determine their motivation level.

Questions to ask the individual

1. In the past month, have you been actively trying to lose weight? Y/N 2. In the past month, have you been actively trying to keep from gaining weight? Y/N 3. Are you seriously considering trying to lose weight to reach your goal in the next 6 months? Y/N 4. Have you maintained your desired weight for more than 6 months? Y/N

Stage Q1 Q2 Q3 Q4

Pre-contemplation N N N

Contemplation N N Y

Action Y on Q1 or Q2 N

Maintenance Y on Q1 or Q2 Y

Pre-contemplation these individuals are not considering losing weight in the next 6 months. Reassess readiness to change at future appointments.

If the individual is at contemplation, action or maintenance position on the cycle of change he or she is appropriate for a weight management programme.

Please note that the following groups of individuals will not be accepted:

10/05/2017  Pregnant  Uncontrolled Serious Mental Illness affecting ability to engage with programme  Non-English speakers and people with Learning Disability will require further assessment  “Pre-diabetes – Please refer to Walking Away From Diabetes Oncology patients who have completed treatment – Please refer to GSTT cancer weight management programme via email link : [email protected]

Please refer to either Tier 2 OR Tier 3, according to suitability and eligibility criteria

Tick here to select □ Tick here to select □ TIER 2 SERVICE TIER 3 SERVICE 12-week programme offering 12-month structured programme of GROUP based  Structured physical activity sessions  Nutrition education GROUP sessions  Clinician led MDT to support the complex needs associated with severe obesity  Behavioural Change Techniques

I confirm that this individual is able to exercise I confirm that this individual is able to exercise at at moderate intensity YES / NO moderate intensity and consent to referral to ‘Active I confirm that this individual is not awaiting or Boost’ undergoing Physiotherapy YES / NO YES / NO ELIGIBITY CRITERIA ELIGIBITY CRITERIA  Age 18 or over  Age 18 or over  BMI ≥30 (or of Asian origin with a BMI  BMI ≥40 + (or of Asian origin with a BMI ≥37.5 over 27.5  Should have had a weight loss intervention at Tier 2 and/or tried commercial programmes

LAST NAME FIRST NAME Mr / Mrs / Miss/ Other ADDRESS GP Post code Practice Address Post Code DATE OF BIRTH TELEPHONE NO /E-mail

TELEPHONE NO / E-mail ETHNICITY

PLEASE AUTO-POPULATE FROM EMIS WEB CURRENT/PREVIOUS MENTAL HEALTH PROBLEMS  Full Blood Count YES / NO 10/05/2017  Lipids Depression □  Thyroid Function Test Anxiety disorder(s) □  Renal Function Test Other □  Liver function Test  HbA1C If not available please confirm these have been requested by GP YES/NO Free text box NHS N0: Sex M / F Pregnant YES / NO

PLEASE AUTO-POPULATE FROM EMIS WEB PLEASE AUTO-POPULATE FROM EMIS WEB BMI WEIGHT HEIGHT REFERRER AND CLIENT CONSENT BLOOD PRESSURE The referral has been discussed with the individual who has given their consent. YES / NO

Are there any safety OR security issues involved Referred by : (please print) in seeing this client? Date of referral YES / NO Designation (if not GP) If yes, please describe the issues 1. PLEASE AUTO-POPULATE FROM EMIS WEB FULL MEDICAL HISTORY AND EMIS CURRENT & PAST PROBLEM LIST

2. PLEASE NOTE ANY ADDITIONAL CO-MORBIDITIES THAT ARE EXACERBATED BY OBESITY

3. FULL DRUGS LIST

4. ALLERGIES

10/05/2017