Please be aware that all fields on the form are mandatory and need to be fully completed to support the FREED referral process.
Please ensure that you upload bloods and an ECG, preferably taken on the day of the referral.
All inappropriate referrals will be sent back to the referrer with recommendations attached, or signposted to the appropriate agencies if they are not suitable for specialist services.
If you have any questions before completing this form, please email email@example.com or call (01472) 808450.
A. There is weight loss leading to a body weight at least 15% below the normal or expected weight for age and height.
B. The weight loss is induced by avoidance of fattening foods.
C. There is a self-perception of being too fat, with an intrusive dread of fatness, which leads to a self-imposed low weight threshold.
D. A widespread endocrine disorder, involving the hypothalamic pituitary gonadal axis, is manifest in women as amenorrhoea and in men as loss of sexual interest and potency.
A. There are recurrent episodes of overeating (at least twice a week over a period of 3 months) in which large amounts of food are consumed in short periods of time.
B. There is a persistent preoccupation with eating, and strong, desire, or a sense of compulsion to eat (craving)
C. The patient attempts to counteract the “fattening” effects of food by one or more of the following:
D. There is a self-perception of being too fat, with an intrusive dread of fatness (usually leading to being underweight).
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.