NEPEAN FAMILY OBESITY SERVICE
ADULT WEIGHT MANAGEMENT CLINIC REFERRAL
 Please note that there is a separate referral form for paediatric patients. If you are referring several members of one family, please indicate this on the referral. If you believe that your patient needs an urgent review, then contact the service by telephone directly (contact details listed below).

OTHER FAMILY MEMBER(S) REFERRED OR KNOWN TO SERVICE (*see below)
YES □	NO □

In addition to this referral, please provide: 
•	an up-to-date medication list 
•	a medical summary 
•	any other relevant documents.

Dear Dr Kathryn Williams/Dr Sharon Yeoh/Dr Anna Zheng, 
Thank you for seeing my patient, ______________________________________, of (address of patient)
_______________________________________________________________ date of birth ___/___/___, 
contact phone number ______________________ in consultation for weight management.
Their current measurements include:
Date of measure: ____________	Weight:____________kg		Height:___________ m
Calculated BMI:___________kg/m2	Waist Circumference:____________ cm
My patient is of Aboriginal, Torres Strait Islander or Polynesian background (please circle): YES / NO
My patient requires an interpreter: YES (specify language:				) / NO
My patient can read AND write: YES / NO	My patient is a current smoker or quit <3 months ago: YES/NO
My patient is willing to engage with an obesity service and understands that this means appointments with doctors, psychologists, physiotherapists, dietitians and nurses and that group sessions are involved: YES/NO
My patient may have problems attending groups and/or appointments at Nepean Hospital due to (tick all that apply and provide details in the space provided*):
□ Restriction to mobility	Details ________________________________________________________
□ Mental health problem	Details ________________________________________________________

Other clinical details/comments and/or family details if relevant*:

□ Social Circumstances/Other	Details ________________________________________________________
Please see next page for referral criteria for your completion.
Name of Doctor: ____________________________________ Signature: ____________________________

Nepean Family Obesity Service, Level 5 South Block, Nepean Hospital
PO Box 63 Penrith, NSW 2751
Ph (02) 4734 4533 Fax (02) 4734 1920
NBMLHD-NepeanFamilyObesityService@health.nsw.gov.au
For appointments please fax or email this referral to the above contacts

Practice Address _________________________________________________________________________
Practice Phone Number: __________________ Practice Fax Number:__________________ Date: ___/___/___		                               
REFERRAL CRITERIA FOR NEPEAN FAMILY OBESITY SERVICE
Dear Doctor
Please indicate which service criterion/criteria your patient satisfies and provide supporting evidence for this with your referral (e.g. blood tests, liver biopsy reports, sleep study reports, specialist letters) if relevant. Supporting evidence is mandatory for some categories* and, if not provided at the time of referral, will delay the acceptance of your patient onto our wait list. We appreciate that the list below does not cover all patients that could benefit from an obesity service. We continue to work with our LHD and with NSW Health with an aim to improve services for those individuals who are above a healthy weight. Should you have any concerns, please do not hesitate to contact us directly.
Kathryn Williams, Clinical Lead of the Nepean Family Obesity Services
Group A	BMI > 35 kg/m2
and any of the following:	Type 2 diabetes on multiple daily insulin injections (basal and bolus therapy) or with HbA1c > 8.5% within the last 3 months*	□	
		Non-alcoholic fatty liver disease with NASH or ≥ F2 on liver biopsy or with FibroScan® > 10.3 kPa*	□	
		Severe Obstructive Sleep Apnoea (RDI > 30) or Obesity Hypoventilation Syndrome*	□	
		Specific end-organ condition directly related to obesity (e.g. obesity-related cardiomyopathy or focal segmental glomerulosclerosis)*	□	
		Planning pregnancy within the next 24 months	□	
		Age < 30 years	□	
		Assessed as appropriate for bariatric surgery by a surgeon actively participating in the public bariatric surgery program (admission by direct discussion between surgeon and Clinical Lead only)	□	
		Another family member being seen in the Family Obesity Service	□	
		Aboriginal or Torres Strait Islander background	□	
Group B	BMI > 50 kg/m2
and any of the following:                                                                                                                                                                                                                                                                                                                             	Any Type 2 diabetes, pre-diabetes or history of GDM*	□	
		Resistant hypertension (BP not controlled on ≥ 3 agents) or evidence of end-organ effects from hypertension (e.g. LVH or albuminuria)*	□	
		Mobility < 20m due to shortness of breath or pain that is likely to improve with weight loss	□	
		Antipsychotic or > 3 months of supraphysiological steroid use	□	
		PCOS with oligoamenorrhoea or dysfunctional uterine bleeding	□	
		Moderate Obstructive Sleep Apnoea (RDI > 15)*	□	
		On list for surgery and required to lose weight to reduce operative risk*	□	
		Recent frequent presentations to hospital (>2 within last 6 months) or prolonged admission (> 1 month) due to obesity related condition*	□	
		Severe lower limb lymphoedema exacerbated by obesity	□	
		High Framingham CVD risk score (2008) – requires data used for calculation	□	
Group C	BMI > 70 kg/m2
and	Willing and able to attend visits at Nepean Hospital using own transport	□	
		May require home visits, telehealth and/or phone coaching
Reason:_____________________________________________	□