The Oxford Bariatric Service (OBS) Referral
NICE Clinical Guideline 43: Obesity defines morbid obesity as people with:
 Body mass index (BMI) ≥40 kg/m2
 Or BMI between 35 - 40 kg/m2 and other significant co-morbidity (e.g. diabetes, high
blood pressure) that may be improved if they lose weight.
NICE recommend that surgery to aid weight loss should be available as a treatment option
for people with morbid obesity provided that they meet all of the following criteria.
Note: Bariatric surgery is recommended as a first line option for people with a BMI ≥50kg/m2
in whom surgical intervention is appropriate
http://guidance.nice.org.uk/CG43/NICEGuidance/pdf/English
Meets criteria?
(Y / N)
Criteria
Aged 18 years or over
Morbid obesity present for 5 years or more
Has participated in a medical weight-loss programme (e.g. OWLS
Oxfordshire weight-loss lifestyle service)
Tried all other appropriate non-surgical treatments to lose weight but
has not been able to maintain weight loss e.g. diet, medication,
counselling
No specific medical or psychological reasons why they should not have
this type of surgery e.g. drug or alcohol dependency, binge eating
disorder
Patient is aware of the requirement for follow up within the bariatric
service for 2 years after surgery
Patient details
Name
Address
DOB
NHS number
Telephone
GP
GP telephone
GP address
Oxford Bariatric Service Referral Form
April 2014
Weight history
Most recent weight (kg)
Height (m)
Date of weight
BMI (kg/m2)
Period of time spent in medical weight loss programme
Medical History
Tick any medical conditions relevant to this individual and provide additional details.
Attach list of current medications if required.
Send any relevant letters of investigations e.g. cardiology or respiratory reviews.
Condition
Tick
Further information
Type 2 Diabetes
Insulin / tablet / diet treated
Medication & doses:
Type 1 Diabetes
Medication & doses
Heart disease
Medication:
Obstructive sleep apnoea
*See comment below
High blood pressure
CPAP required / no formal sleep study
Epworth Score:
Stop bang:
Medication:
Respiratory disease
Medication:
Polycycstic ovarian syndrome
(PCOS)
Dyslipideamia
Medication:
Arthritis / limited mobility / joint
pain
Depression / anxiety
Details:
Allergies
Specific allergens:
Please indicate smoking status
**See comment below
***Please provide recent
biochemistry and haematology
blood results as listed. Referrals
received without these results will
encounter delays until we receive
these results.
Never / Ex-smoker /Currently smokes
Oxford Bariatric Service Referral Form
Medication:
Details of treatment:
Electrolytes: Sodium, potassium, urea,
creatinine, phosphate, magnesium,
calcium, serum bicarbonate, glucose
Liver function test including GGT
Vitamin B12
Lipids: Total Cholesterol, LDL, HDL, Tg
HbA1c
TSH & FT4
Vitamin D
Red Cell Folate, Serrum Ferritin, Total Iron
Binding Capacity, Serum Iron, FBC
If Diabetic: Urinary Microalbumin to
creatinine ratio(MACR)
April 2014
Provide details of other relevant medical conditions:
Important Please Note:
*To avoid delays in this process please assess your patient for sleep apnoea if not already
treated or recently assessed. Stop bang and Epworth charts can be accessed from the
following website under online sleep tests (www.britishsnoring.co.uk). If appropriate refer
to the sleep clinic, all patients will require at least 6 weeks on CPAP prior to progressing
for surgery.
**Unfortunately patients will not be offered surgery if they currently smoke, please advise
your patient of appropriate cessation support if applicable.
***To avoid delays please ensure the appropriate blood results are attached to the
referral form. This will enable the team to expedite referrals to the appropriate bariatric
team member. You will be asked to send this information prior to your patient being seen
in our assessment clinic if it is not included.
This referral has been discussed with the patient.
Appropriate referrals will be assessed by the Oxford Bariatric Surgery Team.
Referrals from secondary care – send copy of referral to GP for information.
Signed
Date
Job title
Post:
Stephanie Little, Clerical Officer, Surgery Admin, Level 0, Cancer Centre, Churchill
Hospital, Oxford, OX3 7LE
Fax:
FAO Stephanie Little 01865 235 676
Email: lisa.rickers@nhs.net
Oxford Bariatric Service Referral Form
April 2014