FATIGUE AND BREATHLESSNESS MANAGEMENT REFERRAL FORM

Please ensure the patient has been assessed as well enough to attend within 3 weeks of the next course commencing(see website for dates).

Please fax completed referral forms to our Access Team on0117 9811405

Please Note: Referral to this course does not constitute a referral to St Peters Hospice Specialist Palliative Care Service

Name:
D.O.B: / Hospice No(if applicable):
N.H.S. No:
Address:
Telephone No:
G.P.
Telephone No: / D.N.:
Telephone No:
Diagnosis and relevant PMH of note:
(e.g. diabetes, angina, epilepsy)
What do you hope the patient will gain from this course?
* Please attach a copy of current medication and recent clinical letters
Next of kin: / Contact Number:
Does the patient use oxygen? Yes/No Litres per minute:
PleaseENSUREthe patient knowsto bring enough oxygen for the 2 hour program and travelling time and to bring any medication they may need.
Please sign to confirm the patient is aware of your referral and you have printed them out the FAB patient leaflet (see link below to print leaflet)
Patients will only be accepted if consent has been obtained from the patients medical advisor (GP/Consultant) for the named patient to attend and exercise. Please sign to confirm consent has been obtained.
Has the patient completed a DNAR or AAND form?
If yes, please send a copy with this referral. / Yes/No

SPH Transport criteria: St. Peter’s Hospice will provide transport to patients who are unable to drive themselves, or have no family/ friends able to do so.

The patient must able to get out of their house and in and out of a car independently, as all transport is provided by volunteer drivers.

If the patient needs more assistance it is the referrers’ responsibility to arrange transport to and from the destination.

Does the patient require transport? / Yes / No
Do they meet SPH criteria? / Yes / No

If yes please complete the transport form below.

ACCESS DETAILS
Type of property?
Driveway? / Yes / No
If the car cannot be parked immediately outside the house can the patient safely walk to where the volunteer needs to park it? / Yes / No
Any access issues the volunteer driver should be made aware of?
Please comment: / Yes / No
PATIENT’S NEEDS
Does the patient use a walking aid? / Yes / No
Will this fit into a normal sized car? / Yes / No
Will the patient be bringing portable oxygen with them? / Yes / No
Does the patient have a preference for sitting in the front or back of the car? Please comment:
(On occasions a driver will bring in more than one patient) / Yes / No
Can the patient wear a seat belt? / Yes / No
Does the patient have any other needs we should know of, e.g., hearing, sight, communication difficulties?
Please comment: / Yes / No
Will there be anyone at home when picked up? / Yes / No
Will there be anyone at home on return? / Yes / No
If not suitable for a SPH volunteer driver please state what alternative transport you are arranging:
AUTHORISATION
Signature of person completing this form / Contact number:
Name in capitals: / E-mail:
Position: / Date:

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