Chelsea and Westminster Hospital
NHS Foundation Trust

REFERRAL FORM FOR PAEDIATRIC DIETITIAN OUTPATIENT CLINIC

Please ensure that you complete all sections and fax form to:
DEPARTMENT OF NUTRITION & DIETETICS
Fax 020 8746 8077	General Dietetic Enquiries 020 8746 8178

PATIENT	REFERRER	
Name	«PATIENT_Forename1» «PATIENT_Surname»	Name	«PATIENT_Registered_GP»	
Address	«PATIENT_BlockAddress»	Address	«PRACTICE_BlockAddress»	
Telephone	«PATIENT_Main_Comm_No »	Telephone	«PRACTICE_Main_Comm_No»	
DoB	«PATIENT_Date_of_Birth»	Fax	     	
NHS Number	«PATIENT_Current_NHS_Number»	E-mail	     	
Gender	«PATIENT_Sex»	Date	«SYSTEM_Date»	
Interpreter Required	Yes 	No 	Signature	     	
Language	     	Patient Hospital number if known	     	
Ethnicity	     			
				
ANTHROPOMETRICS				
Weight	      kg	Height	     	
	
REASON FOR REFERRAL	
REASON	CRITERIA REQUIRED	
FTT	 Downward deviation in weight of two or more major centiles for more than one month
 A greater than 2 centile discrepancy between weight and height centiles	
OBESITY	 Obese children i.e. BMI > 98th C of the 1990 reference chart for age and sex
 Overweight children i.e. BMI > 91st C of the 1990 reference chart for age and sex who also have obesity related morbidity (e.g. benign intracranial hypertension, sleep apnoea, obesity hypoventilation syndrome, orthopaedic problems or psychological morbidity)
 Children with suspected underlying medical (e.g. endocrine) cause of obesity including all children under 24 month of age who are severely obese (BMI > 99.6th centile)	
NUTRITIONAL DEFICIENCY	 Anaemia
 Rickets	
FOOD HYPERSENSITIVITIES	 Immediate reaction	 Eczema	 Vomiting	 Diarrhoea	 Lactose intolerance
 Coeliac	 Other please state      
(please give further information in box below)	
NUTRITIONAL SUPPORT	 NG feeds		 PEG feeds
(please give further information in box below)	
FEEDING PROBLEMS	 Behavioural		 Unsafe to swallow	
OTHER	 Autism : fussy eating		Autism : exclusion diet	 Migraine	
OTHER MEDICAL INFORMATION	
     	
FOR OFFICE USE ONLY	
Date Received:      		 Accepted		 Rejected
Reason:	 Returned for further information	 Does not meet referral criteria	

REFERRALS FOR “POOR APPETITIE/INTAKE/DIET”, “OVERWEIGHT”, “GAINING WEIGHT SLOWLY/SMALL FOR AGE” WILL NOT BE ACCEPTED WITHOUT ONE OF THE ABOVE CRITERIA HAVING BEEN MET