For information please see Musculoskeletal folder on G-Care
Please complete this form fully to enable the service to select the correct course of treatment.
Only send the content of this form and required attachments – there is no need to send a separate letter
Patient to be referred to:
Service
Organisation
Location
Email Address:
Please complete and attach this referral to the eReferral for the Appropriate Service
For patients with current private medical insurance which could cover this referral, please confirm they wish to proceed with an NHS referral. Information from the CCG is available to assist with this discussion (see G-Care link above for info)
Patient details / Patient background and culture
Surname: / Ethnicity:
Forename: / 1st language:
Known As: / Interpreter required? / Yes No
DOB: / GP details
Sex: / Referring Clinician:
Title: / GP Organisation:
Address: / GP Address:
NHS No: / GP Tel no:
Hospital No.: / GP Fax no:
Home tel: / GP Email:
Work tel: / Date of ref.:
Mobile tel: / Date ref received:
Email:
Clinical details
Clinical problem / suspected diagnosis:
Presenting condition e.g. pain score, body part, signs and symptoms
History of Presenting condition e.g. Mechanism of injury, duration of onset, etc.
Interventions already tried in this patient for this problem
Brief reason for referral:
e.g. diagnostic uncertainty, consideration of surgical or medical management, advice on management, support with self-management
Relevant investigations / Attach appropriate: ECG, FBC, C&Es, CXR, USS, imaging reports, neurophysiology, etc.
Does your patient need a specialist chronic pain medicine
review in a consultant clinic?
If this patient has been seen before about this problem who have they seen?
Narrative of referral letter / additional information if required:
Operative risk factors and co-morbidity
Issue / MANUALLY ENTER DATA / Additional Information
Anaemia? / Date:
Hypertensive? / Date:
Diabetes? / Date:
Stroke / TIA / MI
in the past 3 months? / Date:
Are there any other significant illnesses that the receiving service should be aware of?
Are there any relevant personal or social circumstances? e.g. are they a carer
Social Factors information to assist prioritisation
Has the patient received physiotherapy for this problem already? / Yes No
Is pain disturbing the patient’s sleep? / Yes No
Is the patient off work due to this problem? / Yes No
*If yes, how long has the patient been off work? / <1 month
2 months
3 months or more
Is the patient a carer for a relative? / Yes No
Issues affecting Access
Reading / Automatic Data / Date of Latest Reading
Patient’s weight / Date:
Patient’s BMI / Date:
Patient’s BP / Date:
Is the patient able to go up and down stairs? / Yes No
Does the patient use a Mobility Scooter / Yes No
Please enter below any information relevant to this referral which will assist the receiving service in treating the Patient:
Medication
Medical History
Allergies
Smoking Status:
Gloucestershire CCG MSK Referral Template – V1.1 (INPS Vision) 20160725Page 1 of 2