Referral letter – obesity

Notes
Model letter sample 1

Model letter sample 2

Dr D Kurac (name of doctor you are referring the patient to)

Surgeon
Weight center (address)
393 Victorian Road
Richmond, Melbourne

15 June 2018 (Date – format doesn’t matter)

Dear Dr Kurac (Dear name of doctor.)

Re: Andy Williams, aged 65 years old (Re: patient and age / DOB. If age and DOB are
both given, write DOB instead)

Paragraph one: Patient / Condition / Purpose – formats are more or less fixed for all
referral letters

Patient – Andy Williams. Condition – obesity. Purpose - Evaulation of obesity and

recommendation for treatment (but in paragraph 1, lets keep it brief – evaluation and
treatment. We will save the details - Evaulation of obesity, recommendation for
treatment for the last paragraph aka request)

 I am referring Andy Williams (*Patient), who has been suffering from obesity
(*Condition), to you for evaluation and treatment (*Purpose)

 I am writing to refer Andy Williams (*Patient) to you. He has been suffering from
obesity (*Condition). Your evaluation and treatment (*Purpose) would be highly
appreciative.

 Thankyou for seeing Andy Williams (*Patient), who has been suffering from obesity
(*Condition). for evaluation and treatment (*Purpose)

Paragraph 2

Details: 163 cm, 155.5 kg, BMI 46.6, family history of obesity, medical history (type
2 diabetes, hypertension, sleep apnea, BG levels 100-130 mg/dl, triglycerides 201 mg/dl,
serum insulin insulin 19 IU/ml). Medications (30 and 70 units of NPH insulin before
breakfast / before or after dinner, 850 mg metformin twice daily, atorvastatin,
lisinopril and nifedipine)

Mr Williams has a family history of obesity. He weighs 155.5 kg and his BMI is around
46.6 kg/m2. He presents with diabetes, hypertension and sleep apnea. Lab reports showed
(revealed) that his blood glucose was within 100-130 mg/dl and serum insulin and
triglycerides were 19 IU/ml and 201 mg/dl respectively. His medications included 30 and
70 units of NPH insulin before breakfast / before or after dinner, 850 mg metformin
twice daily, atorvastatin, lisinopril and nifedipine.

Paragraph 3

Details: Childhood obesity, gains weight every decade, at highest adult weight,
participated in commercial and medical weight loss programs, consulted registered
dietician,

Mr Williams has been suffering from obesity since he was a child. He participated in
various weight loss programs and even consulted a dietician. However, these failed to
tackle his obesity problem (failed to reduce his weight to an acceptable range)

*Alternatively, it might be better to combine: family history of obesity, weighs 155.5

kg, childhood obesity together into one paragraph and diabetes / hypertension, lab
reports, medications into one paragraph

Paragraph 2

Mr Williams has a family history of obesity. He has been suffering from obesity since
childhood. Despite participating in various weight loss programs and consulting a
dietician, he continues to put on weight and currently weighs 155.5 kg with a BMI of
46.6 kg / m2.

Paragraph 3

Mr Williams presents with diabetes, hypertension and sleep apnea, for which he is taking
30 and 70 units of NPH insulin before breakfast / before or after dinner, 850 mg
metformin twice daily, atorvastatin, lisinopril and nifedipine. Lab reports showed that
his blood glucose fell within 100-130 mg/dl and serum insulin and triglycerides were 19
IU/ml and 201 mg/dl respectively.

Paragraph 4 Details: Diet - 3 meals / day. Reports limited fast food consumption 2
nights / weeks, no alcohol, reports binge eating triggered by stress，plan - Concerned
about health / wants to get life under control, wants to learn about surgical options,
partner encouraging.

Mr Williams eats 3 regular meals per day. He limits fast food consumption and doesn’t
drink any alcohol. However, he claims (reports / said that) to binge eat occasionally
due to stress. He has the support of his partner and is considering surgical treatments
that may help him get his weight and general health under control.

Paragraoh 5 - Request: more or less the same format for all referall lettes - In the
view of above, kindly evaluate ……

Details - Evaulation of obesity, recommendation for treatment

In the view of above, kindly evaluate Mr William’s condition and suggest him the most
appropriate treatment regime. Should you have any questions, please do not hesitate to
contact me.