Surname: / Referring GP:
Forename: / Usual GP:
Address: / Address:
Postcode: / Postcode:
Home tel: / Tel:
Daytime tel: / Fax:
Date of Birth / NHS Number:
Reason for referral / Knee / Hip
Referral Letter
Patient data (where relevant and with dates) / BMI / BP / Smoker / Y / N
Please confirm the following. Providers have been asked to reject or cancel referrals that do not contain sufficient information required to treat or assess the patient. / Yes
1. The patient has no red flags which would indicate an immediate referral to secondary care
2. The patient has had Radiography or an MR scan within the last 6 months that show marked degenerative changes at referral.
3. The patient has persistent and severe pain secondary to arthropathy that has not been adequately controlled by maximum level analgesia and conservative treatment in primary care or an interface service during the last 6 months
If no to Q3, provide further details of why the patient should be referred onwards.
4. The patient is ready, willing and fit to have surgery within 18 weeks
5. Oxford Score
The patient has had their Oxford Hip/Knee Score recorded as an aid (not a barrier) to referral. Surgery is not normally indicated if the Oxford score is less than 16 (out of 48 with 48 being the worst score)
Hip score / Knee score
6. Where surgery is indicated, the patient understands the risks and benefits of surgery and has discussed these with me
7. The patient’s blood pressure is within normal limits/controlled limits (<180/95)? If not please treat and then refer.
8. The patient’s BMI is less than 40? (If > 40, please consider a weight reduction programme unless surgery is essential)
9. Does the patient have a leg ulcer or open wound? (If so, please note this is considered to be an infection risk and an operation will not be performed until it has healed)
Current consultation:
Active problems:
Medical history
Repeat prescriptions:
Drug allergies
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