Name
*
First Name
Last Name
Address 1
*
Town/City
*
Postcode
*
Email
*
Date of Birth
*
What is the name of your GP and the address of your GP practice.
*
GP Consent
*
By ticking this box I understand that SYEDA will contact my GP if there are any serious concerns about my mental/physical well being.
Are you pregnant or have you recently given birth?
Do you have diabetes?
How long have you been experiencing food issues?
*
Have you lost or gained weight in the past 6 months?
If yes, please could you advise how much weight you have lost/gained?
Do you have difficulties with eating - involving avoidance or restriction of certain foods or of overall amount eaten – that are NOT explained by a diagnosed medical condition?
*
Yes definitely
To some extent
Not at all
Unsure
Are your eating habits related to you thinking that you are too big or too heavy?
Yes definitely
To some extent
Not at all
Unsure
Over the past 3 months, has your eating led to difficulty maintaining a healthy weight, or if you are still growing, difficulty gaining enough weight to grow as expected?
Yes definitely
To some extent
Not at all
Unsure
Do you have any nutritional deficiencies or inadequacies as a result of limited eating (e.g. low iron, low vitamin B12, low vitamin C)?
Yes definitely
To some extent
Not at all
Unsure
Do you depend on tube feeding or nutritional supplements to maintain your nutrition, weight or growth (i.e without these you would have nutritional deficiencies or lose weight)?
Yes definitely
To some extent
Not at all
Unsure
Does your eating have a negative effect on your day to day life or your ability to participate in a full range of age-appropriate activities?
Yes definitely
To some extent
Not at all
Unsure
Does your eating have a negative effect on your family/partner relationships or other aspects of your family life (e.g. going out together, on holiday, etc.)?
Yes definitely
To some extent
Not at all
Unsure
Have you seen your GP about your food issues?
Are you currently receiving any support from other services i.e CMHT, CAMHS etc for an eating disorder or other difficulties?
*
If yes, what support are your receiving and where from?
Are you currently receiving or have you previously received dietetic input?
*
If yes, please could you give an overview of the advice that you recevied from them.
Have you previously received support for ARFID?
*
If yes, please could you advise what support you received and where from?
Please could you provide as much information as possible about your behaviours relating to eating difficulties and the support you feel you need
*
Please could you list the foods that you regularly eat as part of your diet.
Please list any nutritional supplements, or prescribed medication from your GP for your diet?
If you are under the age of 18, has another person completed this form on your behalf?
This could be a parent, carer or a professional
Who would you like us to contact to discuss your referral?
If other, please confirm their details below:
This should include their name, relationship to you, their contact number and email address.
I would describe my ethnicity as:
Choose an option
White – British
White – Irish
Any other white background (please specify below)
Indian
Pakistani
Bangladeshi
Any other Asian background (please specify below)
White & Black Caribbean
White & Black African
White & Asian
African
Somali
Caribbean
Black British
Asian British
Chinese
Any other Black background (please specify below)
Any other mixed background (please specify below)
Any other ethnic group (please specify below)
Prefer not to say
Gender identity
Is the gender you identify with the same as your sex registered at birth?
How do you identify?
Sexual orientation
Do you consider yourself to have a disability?
Do you have any other Mental Health difficulties or consider yourself to be neurodivergent?
Please answer this question whether you have an official diagnosis, or consider yourself to have any of the above conditions.
Do you have any additional accessibility needs that you feel we should be aware of?
For example you may require a hearing loop, documents supplied in braille or a translator.
Thank you for your referral.
