<p>Tier 3 Weight Management Pathway REFERRAL FORM</p><p>Referrer Information: Referrer Name: Referral Date: Designation: GP Usual GP: GP Practice: Practice Address: Postcode: Telephone No: FaxF No: E-mail address:</p><p>Patient Details: Forename: Surname: Date of Birth: Address:</p><p>Postcode: Is the patient housebound: Gender: Preferred contact time: Employment: Does the patient smoke: Is the patient pregnant: ☐ Yes ☐ No Units of alcohol per week: Alcohol Consumption If you answer yes to any of the questions below, please provide supporting information: Date Value Does the patient have a learning difficulty: Does the patient require translation / communication support: Does the patient have any disability or mobility issues that the service should be aware of: Weight Management - Patient Record: Date of last recorded measurements: Height: cm Weight: kg Is the patient to be considered for Bariatric Surgery? ☐ Yes ☐ No </p><p>☐ PLEASE NOTE THAT THIS SERVICE OFFERS A PHYSICAL ACTIVITY ELEMENT. PLEASE TICK THE BOX IF YOU CONSENT TO THE PATIENT COMPLETING PHYSICAL ACTIVITY</p><p>Patient Comorbidities: MAJOR Type 2 Diabetes, requiring insulin or another high cost ☐ drug or use of 2 or more HA agents, diabetic complications. Established coronary heart disease, transient ☐ ischaemic attack (TIA) or stroke (if good functional recovery), heart failure, peripheral vascular disease</p><p>Severe obstructive sleep apnoea (sleep apnoea ☐ requiring treatment) or obesity hypoventilation syndrome</p><p>☐ Hypertension requiring the use of 3 or more drugs</p><p>☐ Other please state: Patient Name: DOB: NHS Number: Patient Comorbidities: MINOR Patient Comorbidities: MINOR Infertility/polycystic ovary syndrome, male hypogonadism where weight loss is required prior to ☐ In-vitro fertilisation (IVF), where a couple meet all the other criteria other than BMI of the woman, and the woman is less than 38 years old Diabetes requiring only one Oral Hypoglycaemic ☐ Agents (OHA) or diet controlled ☐ Hyperlipidaemia not controlled by statin alone</p><p>Other ☐ please state:</p><p>Additional information: </p><p>☐ PLEASE TICK TO CONFIRM THE PATIENT AGREES TO REFERRAL DATA BEING STORED AND PROCESSED BY THE TIER 3 WEIGHT MANAGEMENT SERVICE Please return fully completed referral form to: Email: [email protected]</p><p>Office Use Only: Received: SN/BA.StC / / </p>