Refer to FREED
Diagnosis
Required
Details of person being referred
Title
Required
Forename
Required
Surname
Required
Home address
Telephone number
Required
Alternative telephone number
Email address
Ethnicity
NHS number (if known)
Religion
Medical details
GP's Name
Required
Surgery address
GP telephone number
Required
Source of referral
Name or agency
Required
Referrer's address
Referrer's telephone number
Required
Referrer's email address
Required
Current presentation
To assist, please consult the diagnostic criteria which will help you complete this section. This will open in a new window.
Summary of presenting condition
Required
Current Body Mass Index
Height
Weight
The specific bloods required are FBC, U&E, Phosphate, Calcium, Magnesium, Albumin, CRP, LFT, Iron profile, Vitamin B12 and Folate , Vitamin D, TFT, Glucose, CK.
Please upload bloods below
Please upload the latest ECG
Does the person present with unresolved alcohol or illicit substance misuse? If yes, please specify.
Does the person show any neurological issues? If yes, please specify.
Are the any concerns related to person’s medical condition? If yes, please specify below.
Are there current risk factors? If yes, please specify below.
Does the person have a current treatment plan? If so, please specify below.
Is this person currently using any medications? If so, please specify below.
Has the person been provided with specialist eating disorder input before? If yes, specify below.
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