Note: This referral form is for Outpatient Women’s Health and Musculoskeletal Physiotherapy only. For details regarding how to refer to other Physiotherapy or the Musculoskeletal Centre and FAQs please visit our website()
Please complete this form in full as incomplete/illegible forms will be returned which will delay the referral
PATIENT DETAILS
Title: / Forename(s): / Surname(s):
M F / NHS Number: / D.O.B:
Address (incl. postcode):
Daytime contact number:
(We may contact the patient from a withheld number to discuss this referral) / Alternative contact number:
Is an interpreter required: NO YES If yes, which language:
Does the patient have a learning disability?
ETHNICITY
White British / Any other mixed background / Black/Black British Caribbean
White Irish / Chinese / Black or Black British African
Any other White / Asian or Asian British Indian / Any other Black groups
Mixed: White/Black Caribbean / Asian or Asian British Bangladeshi / Any other ethnic group
Mixed: White & Black African / Asian or Asian British Pakistani / Declined to state ethnicity
Mixed: White & Asian / Any other Asian background
REFERRER DETAILS
Date of referral: / GP/Consultant/Referrer Name:
Contact Number: / Fax Number:
Address:
NHS.net email address: / GP Practice:
TRIAGE
PLEASE INDICATE BODY PART(S): SPINAL UPPER LIMB LOWER LIMB
REFERRAL REASON/DIAGNOSIS AND RELEVANT MEDICAL HISTORY OR ATTACH EMIS REPORT
(If post-operative: Operation details including a copy of op notes, post-op instructions and date of surgery are ESSENTIAL)
(If post-fracture: Date of fracture and mobilising instructions are ESSENTIAL)
PLEASE TICK THE BOXES THAT BEST DESCRIBES THIS PATIENT:
U30 NON-SPINAL SURGERY OR A FRACTURE IN THE LAST 12 WEEKS?
U SPINAL SURGERY OR A FRACTURE IN THE LAST 12 WEEKS?
U INJURY/TRAUMA IN THE LAST 6 WEEKS
U ACUTELY OFF WORK (LESS THAN 6 WEEKS) DUE TO THIS PROBLEM
U PATIENT IS A REGISTERED CARER AND THE SYMPTOMS ARE AFFECTING THEIR CARING CAPABILITY
U CORTICOSTEROID INJECTION IN THE LAST 2 WEEKS
U DIAGNOSIS BY PAIN CLINIC OF CRPS
WHCP INCONTINENCE OR PELVIC ORGAN PROLAPSE / P PREGNANCY RELATED PAIN AND ≥34/40 WH(P)BACK PREGNANCY RELATED BACK PAIN WH(P)SPD PREGNANCY RELATED PELVIC PAIN _____/40
EDD: _____/_____/_____ {INTERPRETER=1:1}
PTAREQUIRES EQUIPMENT PROVISION ONLY (SPLINT, STICK OR CRUTCHES)
R NONE OF THE ABOVE
DOES THE PATIENT REQUIRE AN APPOINTMENT WITHIN:
5 WORKING DAYS? YES NO IF YES PLEASE INDICATE REASON:
OTHER SPECIFIC TIME (E.G POST-SURGERY?) YES NO IF YES PLEASE STATE TIMEFRAME:
PLEASE NOTE:PATIENTS WHO HAVE HAD UNSUCCESSFUL PHYSIOTHERAPY FOR THE SAME CONDITION WITH NO SIGNIFICANT CHANGE IN THEIR CIRCUMSTANCES ARE UNLIKELY TO BENEFIT FROM RE-REFERRAL. PLEASE CONSIDER REFERRAL TO PAIN CLINIC, COPE OR ORTHOPAEDICS
Please return this referral form to the Sutton Adult Referral Centre:
Email: Fax: 0208 661 3910 Telephone: 0208 661 3908
OPY/WH REFERRAL FORM VERSION 4 OCT 2016