Download Continence Proforma - GP Pilot - Gloucestershire Hospitals NHS

Choose and Book Referral
Patient name:
NHS Number:
Gloucestershire Continence Service
Adults (16years + ) Male /Female
Patient Name ………………………………. NHS Number …………… Date of Birth…………..
Please use this form together with your standard Choose and Book referral letter, which will contain practice details, patient
demographics, relevant medical history and medications. For reference purposes, please can you also complete the patient name
and NHS number in the header above.
NB : Patients with haematuria should be referred to the Urology Rapid Access Clinic
1. The continence service is for patients with symptoms of bladder dysfunction and /or incontinence. If the patient also
has any of the following, please indicate and give details below:
Continuous urinary leakage
Bladder pain
Symptoms of a voiding
difficulty
Previous continence
Prolapse symptoms/signs with
Neurological signs with lower
surgery
lower urinary tract symptoms
urinary tract symptoms
Recurrent, proven lower
urinary tract infections
Urinary retention
Failed conservative management
Reduced fixed volumes on
urinary diary
Abnormal examination, e.g.
mass/fistula/palpable bladder
Other (only to be used in
exceptional circumstances)
Relevant details:
Yes
No
Is the urinalysis/MSSU normal?
Has the Fluid intake been reviewed?
Have significant bowel problems been excluded?
Has current medication been reviewed to exclude
Relevant reactions with bladder function?
Has significant cognitive impairment been identified?
Has any atrophic vaginitis been treated with 2/12 of topical oestrogens?
Has a urinary diary been completed?
This form can be used for referral to the Gloucestershire Continence Service on Fax No. 08454 225311 or If conservative
management is unsuccessful, these services can refer the patient onwards.
3. Please indicate any other relevant history:
4. Relevant current medication:
5. Other significant information:
BMI:
Weight:
BP:
GCS Pilot Proforma .June 2009
Choose and Book – Referral template – Gloucestershire
GP Pilot Proforma – 28th August 2009