Title: *Required
First name: *Required
Last name: *Required
Date of birth: *Required
NHS number:
Address: *Required
Postcode: *Required
Telephone number: *Required
Other telephone number:
We do carry out home visits for patients who are housebound, however the first contact will be by telephone with a dietician to further screen, assess and give initial dietary advice, before a home visit will be offered.
It is essential that a patient can speak with us on the telephone, or can give consent for someone else to speak on their behalf. If this is not possible, please explain:
If a home visit is required, please complete the following risk assessment; if it is not fully complete, the referral may be returned.
If not, please give the contact details & relationship to patient, of who we should contact:
If yes, please provide additional information:
If yes, please provide additional information:
If yes, please provide additional information:
If yes, please provide additional information:
If yes, please provide additional information:
If yes, please give additional information:
Other contact
Full name: *Required
Telephone number: (if different from patient)
GP details
GP name: *Required
GP address: *Required
Referrer
First name: *Required
Last name: *Required
Position: (eg. GP, consultant, nurse) *Required
Department/ward/surgery/nursing home: *Required
Address: *Required
Telephone number: *Required
Diagnosis and reason for referral
Diagnosis: *Required
Reason for referral: *Required
Past medical history: *Required
Weight/centile (P): *Required
Height/centile (P): *Required
BMI: (Body mass index) *Required
MUST/STAMP: (Malnutrition universal screening tool) *Required
Infection status: *Required
Communication needs: *Required
We ask the following question about ethnicity to ensure that we meet the needs of the demographic population of Medway.
Ethnic identity: *Required
Ethnic identity: I do not wish to disclose British Irish Any other white background White and Black Caribbean White and Black African White and Asian Any other mixed background Indian Pakistani Bangladeshi Any other Asian background Caribbean African Any other black background Chinese Any other ethnic category Gypsy/Traveller
Are there any cultural or religious considerations we need to be aware of when planning your treatment?
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