Eating Disorder Self-Referral Form   Please note this Eating Disorders Referral Form is only for registered patients of the University Health Service. If you are a student of the University of Sheffield and are not registered with the University Health Service please contact our Reception team on 0114 222 2100 if you do want to register.   Please complete ALL fields on this form to avoid any delays to your referral.   * Full name:   * Date of birth: Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916   * UK telephone number:   * Email address:    * Confirm Email address:     * Address:     What course are you studying?   NHS No. (if known):     * Height:   cm * Weight:   kg   * How many times a week do you binge eat?     * How many times a week do you make yourself sick?     * How many times a week do you use laxatives?     * How many times do you exercise?     * What types of exercise do you do and for how long?     * Please give a history of your eating disorder:     * What challenges do you face as a result of your eating disorder?     * Statement of consent I understand that my details will be logged by the University Health Service and give permission to be contacted by email/text regarding future appointments: OK Once you have been referred you will be contacted by a member of the secretarial team notifying you of the outcome of your referral.     * = Compulsory Please read our Privacy Notice

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