Bariatric Patient Referral

REFERRING PRACTITIONER

Doctor *

Practice Name *

Provider Number *

Practice Phone *

Email Address *

PATIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth** *

Gender *

MaleFemaleOther

English is a Second Language *

YesNo

Ethnicity

ATSI Status *

AboriginalTorres Strait IslanderNone of the Above

Height (m) *

Weight (kg) *

BMI calculation *

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone

Work Phone

Email *

Address *

Postcode *

City / Suburb *

State *

PATIENT HISTORY

Obesity-related comorbid conditions *

YesNo

*Priority will be given to patients with significant chronicdiseases that are currently not well treated but which are known to respond well to weight loss

Hypertension *

YesNo

Hyperlipidaemia *

YesNo

Type 2 Diabetes Mellitus *

YesNo

Type 2 Diabetes Mellitus (select) *

Diet controlledOral HypoglycaemicsInsulin

Obstructive Sleep Apnoea *

YesNo

Does patient use CPAP? – All referrals must have a complete OSA Risk Assessment *

YesNo

Ischaemic Heart Disease *

YesNo

Respiratory Disease *

YesNo

Respiratory Disease (please specify) *

Fatty Liver *

YesNo

Peripheral Vascular Disease *

YesNo

Musculoskeletal / Joint Disease *

YesNo

Polycystic Ovary Syndrome *

YesNo

Infertility with or without IVF? *

YesNo

Renal Impairment *

YesNo

Renal Impairment (please specify) *

Mobility (other) *

SURGICAL RISK

Smoker *

YesNo

Smoker (status) *

Current smokerEx-smokerActively trying to quit

Date ceased smoking

End Stage Cardiac Disease *

YesNo

End Stage Renal Disease *

YesNo

Advanced Liver Disease with Portal Hypertension *

YesNo

End Stage Vascular Disease *

YesNo

Active Psychosis or Unstable Depression *

YesNo

Active Alcohol / Drug Dependence *

YesNo

Cognitive or Behaviour Disorders affecting decision making *

YesNo

Functional Status *

IndependentSupportedFully Dependent

File Attachments

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Referral must include –

FBE, U&E, LFT, Calcium, Magnesium, Phosphate, HbA1c, Fasting BSL, Insulin levels, Fasting Cholesterol and Triglycerides, B12, Folate, Iron Studies, Thyroid Function Test, Parathyroid Hormone, Vitamin D Level, Latest Respiratory Function Tests, Sleep Study report if patient meets criteria

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