Continence Service Referral Form

Send this form to:

Email:

For Cambridge,Hunts and fenland areas

Email:

For Peterborough area

I am sending an accompanying letter

11th July 2016

Patient's details:

Surname: …….. NHS No: ……..

Forename: …….. Hosp No: ……..

Address: …….. Date of birth: ……..

…….. Daytime Tel: ……..

…….. Evening Tel: ……..

…….. Mobile Tel: ……..

Postcode: …….. Language of choice: ……..

Carer details (if applicable): ……..

11th July 2016

Communication/understanding difficulties: ……..

Referring GP/Consultant details (please print or stamp):

Name: ……..

Surgery address: ……..

Surgery Tel: …….. Surgery Fax: ……..

Referral date: …….. Referral details: ……..

11th July 2016

Clinic Appointment
Clinic Venue Preferred:
/ Cannot attend clinic
Reason:
Home Visit:

11th July 2016

Reason For Referral
Male incontinence
Faecal Incontinence
TWOC / ISC (Consultant referral only)
Reason:
How Frequent:
Comment:
Clinical Details
Bladder Dysfunction Yes No / Catheterisation Yes No
Urethral
Supra pubic
ISC
TWOC required
Stress Incontinence Yes No
Cough/sneeze
Physical activity / Urge Incontinence Yes No
Urgency
Frequency
Nocturia
Prolapse Yes No
Bladder
Bowel
Uterine
Symptomatic Asymptomatic / Voiding Dysfunction Yes No
Recurrent UTIs
Incomplete emptying
Hesitancy/Poor stream
Bowel dysfunction Yes No
Faecal incontinence
Faecal urgency
Constipation / Functional Yes No
Poor mobility
Poor dexterity
Impaired cognition
For review of current management of long-term continence problem Yes No / Duration of symptoms:

Previous treatment in Continence Service

Yes No
By whom:
When:
Where: / Any investigations or previous treatment for continence problem Yes No

Past Medical History – Please detail

/ Surgery Yes - If yes, please detail No

Medication – Please list None Prescribed

/ Containment Measures Yes No
Catheter
Sheath
Incontinence pads
Washable products

Clinical Details Results

NAD or comments:
Seen by GP Yes No
Urine Test Yes No
PV Examination Yes No
PR Examination Yes No

Abdominal Examination Yes No

For Use by Continence Clinic only:

Continence Information Pack to be sent to patient (please tick)
Female Bladder Bowel Male Bladder Bowel
Urgent appointment
Routine appointment / Specialist Nurse
Physiotherapist
Appointment
Date:
Time:
Clinic venue: / Comments:

11th July 2016