AHP Direct Referral Form

AHP Direct Referral Form

Nutrition and Dietetics/Physiotherapy/MSK/Podiatry(Chiropody)/Speech and Language Therapy

Referral information
Referral date / Tick if urgent referral
Which Service is required / Please tick one only
PHY01 – Tier 1 Physiotherapy / POD01 – Podiatry
PHY02 – Tier 2 MSK / NAD01 – Nutrition and Dietetics
PHY03 – Orthotics / SALT – Speech and Language Swallowing
PHY04 – Chronic Fatigue Syndrome / SALT – Speech and Language Communication
PHY05 – CountyDurham Care / SALT – Speech and Language Voice
PHY06 – Pulmonary Rehabilitation / SALT – Speech and Language Stammer
Please ensure all sections of this form are completed in full
Personal details
First name / Surname
Preferred name: / Title / MrMrsMasterMissMsDrOther
Date of birth / NHS number
Address / Daytime tel no
Emergency tel no
Contact name
Can patient/carer communicate by phone? / Yes No
Ethnicity White BritishBritish or mixed BritishIrishOther White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther mixed backgroundIndian or British IndianPakistani or British PakistaniBangladeshi or British BangladeshiOther Asian backgroundCaribbeanAfricanOther Black backgroundChineseOtherEthnic category not stated
Religion
Postcode / Language
Gender / Male Female Other / Height
Occupation / Male Female Other / Weight
GP name
GP Practice address or code
Please tick applicable boxes
Hearing impairment / Visual impairment
Pacemaker / Interpreter needed
Reason for referral/diagnosis
Relevant medical investigation results
Relevant medicalhistory
Current medication or attach prescription list
If other services are involved in patient care, please give details
Comments
Patient
Doctor
Other (please specify):

Referral form completed by:

Name/Title/Address (If different from page1)

Please return to:

AHP Central Referral and Booking Department

Merrington House

Merrington Lane

Spennymoor

Co Durham

DL16 7UT

Tel: 01388 825700

Safe Haven Fax: 01388 825 701

Email:

Adult Obesity Referral Checklist(for medical use only)

Please answer the following questions.

Each criterion MUST be completed.

Please add this completed Checklist to the completed referral form.

Criterion 1 / The patient is motivated and ready to change.YesNo
Criterion 2 / a.The patient’s BMI is greater than 30 (please tick if appropriate)
OR
b.The patients BMI is between 25-30 plus co-morbidities
Please enter the patient’s BMI ……………………..
Criterion 3 / In the last 6 months, the patient has attended primary care, commercial, GP
or leisure services support but failed to lose more than 5% of their weight

In addition to the above please state: -

Do you consider this patient to be suitable for exercise sessions?YES/NO
If no, why not?.
Do you consider this patient to be suitable for group sessions?YES/NO
If not, why not?