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Watch-it Referral Form

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					                                  Birmingham Community Nutrition and Dietetic Service

                              Watch-it Referral Form
Please complete form and fax/post back to:
Watch-It Programme                                                       Tel: 0121 446 1021
St Patrick’s Centre for Community Health                                 Fax: 0121 446 1020
Frank Street
Highgate
Birmingham
B12 0YA

Type of referral (tick as appropriate)        Parental Referral     Professional Referral 

For Parental Referral please complete Sections 1, 2, 3, & 5 providing as much information as
possible. Where did you hear about Watch-It? _____________________________________

For Professional Referral please complete all sections providing as much information as
possible.

Section 1
Name of child            …………………………………………………
Child’s address          …………………………………………………
                         …………………………………………………
                         …………………………………………………
Postcode                 …………………………………………………
Tel. no                  Home………………………………….Mobile………………….…………
Sex                      Male/Female
Ethnicity                …………………………
Is an interpreter required? Yes/No                 If yes, what language? ………………………
Date of Birth            …………………………
Weight                   ………………………… (please state units of measurement e.g. kg)
Height                   ………………………… (please state units of measurement e.g. cm)
BMI (Body Mass Index) ………………………… (we can work this out for you using the child’s
                                                   height and weight measurements)
GP name                  …………………………………………………
GP address               …………………………………………………
                         …………………………………………………
GP Tel. no               …………………………………………………


Section 2

Name of Referrer         …………………………………………………
Relationship of referrer to child (e.g. parent, guardian, GP etc)
……………………………………………………………………………..
Contact Address          …………………………………………………
                         …………………………………………………
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Section 2 continued…
Tel. no                  …………………………………………………
E-mail                   …………………………………………………
Is there, or has there been, any other relevant health professional involvement? (e.g.
psychologist, GP, dietician) ………………………………………………………………………
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..


Section 3

Reason for referral to Watch-it and any other relevant information about the child and family.

Please give as much information as possible, including details on:
- parental concern for child
- any complications caused by obesity (e.g. diabetes, psychological impacts etc)
- possible underlying causes of obesity
- relevant medication details or medical history (e.g. asthma)
- any educational and/or behavioural difficulties
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Section 4
If the referral has not been completed by a parent/guardian, this section must be
completed:
Parental consent for referral obtained: Yes/No
Date obtained:           …………………….
Name of parent/carer giving consent:     …………………………………………………………
Views of parent/carer on referral:       ……………............................................................


Section 5
Referrer Signature…………………………………………………………Date…………………………..

				
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Description: Watch-it Referral Form