Child Weight Management Care Pathway for Cornwall and Isles of
Scilly– Assessment for Co-morbidities or underlying causes - Result
form
Patient Name
Date of Birth
Parent/Carer/Guardian Name
Address
Tel No.
GP Practice
Height (m)
Weight (kg)
BMI and centile
Date measured
Comorbidity/Complication/
Underlying Cause
Relative short stature for degree of
obesity.
Short for mid parental centile
Dysmorphic signs and/or significant
learning difficulties
Present
Hypertension
Symptoms of obstructive sleep apnoea
Significant mobility or joint problems
Glycosuria or raised fasting glucose
Acanthosis nigricans
Abnormal lipid profile
Abnormal LFT’s
Features suggestive of polycystic
ovarian syndrome
Significant family/individual distress
related to obesity e.g. depression, self
harm
Concerns regarding an eating disorder
Child Protection Concerns
Family History of type 2 diabetes
Family History of premature
cardiovascular disease in 1st or 2nd
degree relative
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Result/Comment
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
If one or more co-morbidities present AND the child has a BMI centile >91st centile
OR BMI > +3.5 SD line OR significant suspicion of underlying cause please send this
form along with referral letter to Dept of Paediatrics, Gwithian Unit, 4th Floor Tower
Block, Royal Cornwall Hospital, Truro, TR1 3LJ. If the child is 6 or under please refer
to LEAF clinic, Child Health, Pendragon House, Gloweth, TR1 3XQ.
Assessor Name………………………………………………….Job Title……………………………………
Signature…………………………………………………………..Date………………………………………..
Created by Dr Helen Vickerstaff, Community Paediatrician, RCHT.
Review date June 2015