NEPEAN FAMILY OBESITY SERVICE
KIDS FIT 4 FUTURE CLINIC REFERRAL
If you believe that your patient needs an urgent review, then please contact the service by telephone directly.
Dear Dr Gary Leong
Thank you for seeing my patient, ______________________________________, date of birth ___/___/___, contact phone number(s) _____________________________________ 
Their current measurements include:
Date of measurement: ____________	Weight:____________kg		Height:___________ cm
Calculated BMI:___________kg/m2	Waist Circumference:____________ cm    BP ______________
My patient is of Aboriginal, Torres Strait Islander or Polynesian background (please circle): YES / NO
My patient requires an interpreter: YES (specify language:				) / NO
Parent’s details
Mother’s name:	_____________________ AGE__________ Height________cm   Weight__________
Father’s name_______________________AGE___________Height________cm   Weight____________
Family History of Type 2 Diabetes Mellitus (T2DM) (please circle) if YES, who______________or NO
Early Heart Disease (Myocardial Infarct/CVA) < 15 years (please circle): YES/NO: who____________
Mental Illness YES/NO if YES _____________
Severe obesity requiring treatment YES or NO ______________________
If patient have the following conditions/signs (tick if apply and provide details in the space provided*):
□ Acanthosis Nigracans			□ Obstructive Sleep Apnoea		□ Behavioural disorders:
Specify who and Circle (ASD ADHD, Other mental illness) __________________________________	
□ Non-alcoholic fatty liver disease (abnormal LFTs)	□ Hypothyroidism 

Other relevant clinical details/comments including, other medical illnesses, food allergies, past or current medications, and birth pregnancy details gestation, birth details, etc*:

□ PCOS with established oligoamenorrhoea, hirsutism, hyperandrogenism	□ Orthopaedic problems 
Please attach any other relevant investigation documents to this referral 
Name of Doctor: ____________________________________ Signature: ____________________________
Practice Address _________________________________________________________________________

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 Contact Details: _____________________________ Date: ___/___/___		                               

NEPEAN FAMILY OBESITY SERVICE

Referral Criteria to Family Obesity Services

KIDS FIT 4 FUTURE CLINIC
Family able to attend service with a child who has a:
>120% of CDC BMI 95th centile if no obesity-related complications 
Or >CDC BMI 85th centile if obesity-related complication (Pre-diabetes with string Family history of T2DM, T2DM, Fatty liver disease, Obstructive sleep apnoea, major psychiatric or  psychological disturbance secondary to obesity, benign intracranial hypertension, major orthopaedic complications eg SUFE).