Sutton Adult Community Dieticians

Refe rral Crit eria Sutton Adult Community Dieticians Referrals will only be accepted on the adu l t communi t y dietitian’s referral form. ALL sections must be completed (co p y enclosed) Referrals must be faxed or sent to the address on the referral form

REASON CRITERIA REQUIRED • All Diabetes referrals (Type 1 and 2) should be sent to: Diabetes Specialist Dietitians, Doreen Kouba Diabetes Centre, St Helier Hospital, Wrythe Lane, Carshalton, Surrey, SM5 1AA DIABETES • Impaired fasting glucose or impaired glucose tolerance referrals should be se to the community dietitians. Blood results confirming the diagnosis m u st included. Non-Asian • BMI ≥ 28 plus 2 co-morbidities (e.g., hypertension, raised blood lipids) • BMI ≥ 30 Asian OBESITY • BMI ≥ 25 plus 2 co-morbidities (e.g., hypertension, raised blood lipids) • BMI ≥ 27 OR WAIST CIRCUMFERENCE • Caucasian Men ≥ 102cm (37’’) Asian Men ≥90cm (36”) • Caucasian Women ≥ 88cm (34’’) Asian Women ≥80cm (32”) • Primary Prevention - 10 year CVD risk above 20% (see Cardiovascular Ri CARDIOVASCULAR Prediction Charts (BNF 2011:62). Provide CHD risk percentage and supporti DISEASE lipid results. • Secondary Prevention – include recent lipid profile, e.g. Total Chol, LDL, HD TG’s, etc and BP results • Malnutrition/Underweight - identified as high risk by the MUST (Malnutrition Universal Screening tool (excluding anorexia or bulimia) • Swallowing / feeding difficulties post Speech and Language Therapy (SL NUTRITIONAL assessment (SLT report to be attached) SUPPORT • Enteral Feeding • Review of prescribed oral nutritional supplements • Pressure sores • Inflammatory Bowel Disease (e.g., Crohns Disease, Ulcerative Colitis) GASTROINTESTINAL • Irritable Bowel Syndrome (Clinically diagnosed by NICE GUIDANCE 61 (200 PROBLEMS Criteria)- please indicate how patient meets this criteria • Coeliac Disease (diagnosed by biopsy) – results to be attached and any rece FOOD blood tests INTOLERANCES • Lactose Intolerance (diagnosed by hydrogen breath test/lactose intolerance test) NUTRITIONAL • Anaemia – supporting blood results to be attached DEFICIENCIES • Other nutrient deficiencies e.g. Vitamin D, calcium - supporting blood results be attached PREGNANCY • With special dietary needs e.g. vegan / weight management OTHER DISEASE • HIV/AIDS, cancer/palliation/ neurological condition, e.g. MS, MND, Parkinson’s STATES Disease, PSP, Stroke, etc.

SPECIAL NEEDS Please indicate clearly the nature of the special need, e.g. Learning Difficulties

Please note - we no longer accept referrals for people with eating disorders. Please refer to the nearest specialist service for treatment