Complications of Excess Weight Service

Please send to Samantha Stringer MDT Co-Ordinator at plh-tr.cewservice@nhs.net Based: CEW Team, Paediatrics Level 12, Derriford Hospital, Plymouth ,PL6 8DH Tel: 01752 437294 Date of referral: <Today's date> Name: <Your Name> Profession: __________________ Contact details of referrer: <Organisation Details> ___________________________________________________________________________________
Client details
Surname:<Patient Name> Forename(s): <Patient Name> Date of birth:<Date of Birth> Sex: <Gender> NHS No.: <NHS number> Address: <Patient Address> Telephone number: <Patient Contact Details> E-mail: <Patient Contact Details> Mobile: <Patient Contact Details> Parent / Carers details: <Relationships(table)> GP: <GP Name> Parental consent given for referral: Y / N First language: <Main spoken language> Interpreter required: Y/N Social worker: __________________________ Name and contact details: ________________________________________ Other professionals / agencies involved: _____________________________________________________ Risk / health and safety issues: ____________________________________________________________
Weight/Height/BMI
Weight: ____<Latest Weight>_ Kg Date recorded: Height: ____<Latest Height>__ cm Date recorded: BMI: ____<Latest BMI>____ Kg/m₂ Date recorded: BMI SDS _______ Date recorded:
Complications of obesity
☐Hypertension ☐Sleep Apnoea requiring intervention ☐Metabolic Liver disease ☐Diabetes T2 ☐Polycystic ovarian syndrome ☐Idiopathic intracranial hypertension ☐Other (please state) _______________________
Possible underlying pathology
(EXAMPLE - Genetic cause / Living with learning or physical disability / Secondary cause of obesity suspected etc.)

Anything else relevant for this referral
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Outcome – FOR CEW OFFICE USE ONLY
Date referral received: / / Outcome:
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