<p>REFERRAL FORM</p><p>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</p><p>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. </p><p>Patient motivation - readiness to change</p><p>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.</p><p>Questions to ask the individual</p><p>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 </p><p>Stage Q1 Q2 Q3 Q4</p><p>Pre-contemplation N N N</p><p>Contemplation N N Y</p><p>Action Y on Q1 or Q2 N</p><p>Maintenance Y on Q1 or Q2 Y</p><p>Pre-contemplation these individuals are not considering losing weight in the next 6 months. Reassess readiness to change at future appointments.</p><p>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.</p><p>Please note that the following groups of individuals will not be accepted:</p><p>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]</p><p>Please refer to either Tier 2 OR Tier 3, according to suitability and eligibility criteria</p><p>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</p><p>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 </p><p>LAST NAME FIRST NAME Mr / Mrs / Miss/ Other ADDRESS GP Post code Practice Address Post Code DATE OF BIRTH TELEPHONE NO /E-mail</p><p>TELEPHONE NO / E-mail ETHNICITY</p><p>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</p><p>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</p><p>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 </p><p>2. PLEASE NOTE ANY ADDITIONAL CO-MORBIDITIES THAT ARE EXACERBATED BY OBESITY</p><p>3. FULL DRUGS LIST</p><p>4. ALLERGIES</p><p>10/05/2017</p>