WEST KENT NHS AND SOCIAL CARE TRUST

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WEST KENT NHS AND SOCIAL CARE TRUST Powered By Docstoc
					                                      Eating Disorders Service, The Red House,
                                   22 Oakapple Lane, Maidstone, Kent ME16 9NW
                 Tel: 01622 729980 Fax: 01622 729677 e-mail address: sandra.sargeant@kmpt.nhs.uk


               Eating Disorders Service, Eastern and Coastal Area Offices
                                    Littlebourne Road, Canterbury, Kent, CT1 1AZ
                 Tel: 01227 767062 Fax: 01227 812268 e-mail address: sarah.amerena@kmpt.nhs.uk

                             PRIMARY CARE EARLY INTERVENTION REFERRAL FORM

      ****PLEASE COMPLETE EVERY PART OF THIS FORM IN AS MUCH DETAIL AS POSSIBLE.****
****INCOMPLETE FORMS WILL NOT BE PROCESSED AND WILL BE RETURNED TO THE REFERRER.****

 Name: ............................................. Date of Birth: ....................... NHS No: ......................................

 Address: ............................................................................................................................................

 ..................................................................................................... Ethnicity ......................................

 Telephone No: ...........................................             Mobile Telephone No: .............................................

 Registered GP: ...........................................            Telephone No: .........................................................

 GP Address:......................................................................................................................................
 Use the “SCOFF” questions to identify possible cases of eating disorder:
 Do you make yourself Sick because you feel uncomfortably full?
 Do you worry you have lost Control over how much you eat?
 Have you recently lost more than One stone in a three-month period?
 Do you believe yourself to be Fat when others say you are too thin?
 Would you say that Food dominates your life?

 Score one point for every “yes”; a score of two or more indicates
 a likely case of eating disorder.

 Assessment

                                                                                                                  Frequency
                                                         No                   Yes                   Per day                       Per week
 Missing meals
 Restricting meals
 Binge eating
 Vomiting
 Laxatives
 Diuretics
 Excessive exercise
 Substance misuse (specify)

 Weight ............................. Height................................ BMI ................. Menstruation ........................

 BMI calculation:                 (weight (Kg) ………
                                  [height (m)]2
 Length of history ...............................................................
 (if over 18 months do not use this form, instead refer to secondary mental health services)
 Name of referrer: ........................................................ Title: ...............................................................

 Signature:................................................................. Date of referral: .............................................

				
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