SCI Gateway Protocol Text
Mandatory fields are indicated by an asterisk
- Physical indicators from GP examination – Text
(Gynaecomastia referrals should have hormone levels checked) - Psychological indicators – Text
(Significant and prolonged psychological distress and associated impairment in functioning related to the perceived problem)
Psychological contra indicators
- Major life event within the last year – Tick
- Episode of deliberate self harm within last 2 years – Tick
- Eating Disorder (clinical / subclinical) – Tick
- Substance misuse (illicit or prescribed) – Tick
- Major depressive illness – Tick
- Psychiatric disorder – Tick
- Body dysmorphic disorder – Tick
- Following GP exam has a disproportionate view of problem – Tick
Physical contra indicators
- Currently pregnant or less than one year post natal – Tick
- Please give patient’s current BMI – Text
- If bariatric weight loss patient, please give consecutive BMIs 1 year apart – Text
Previous mental health services contact
- Previous mental health services contact – yes / no
- If yes, please give details – Text
- Do you (GP) support this application – yes / no
