Download LOWER URINARY TRACT SYMPTOMS Referral Form

LOWER URINARY TRACT SYMPTOMS Referral Form
GSTT gynaecology clinic
details
KCH gynaecology clinic details
Gynaecology Out patients
McNair Centre, Guy’s
Hospital SE1 9RT
Gynaecology outpatients, Suite 8,
3rd floor, Golden Jubilee Wing,
KCH, Denmark Hill
London, SE5 9RS
020 7188 2000
0203 299 3246 (option 1)
Fax
020 7188 3674
0203 299 3471
Email
n/a
n/a
Address
Contact details:
Phone
Referral date
System Date
Referring doctor: Referring Doctor
Address:
Practice Address
Stacked
Referral urgency
Patient
name:
DOB:
Title Forenames
Surname
DOB
Address:
(include postcode)
Practice Main Telephone
Phone:
Other
Phone:
NHS number:
Patient Address List
Home Telephone
Mobile Telephone
NHS Number
Hospital Number:
1
2
3
4
5
6
7
8
1
Has a bladder diary been completed for three days?
Has a diagnosis been made, based on the woman’s history, of stress, urge, (over
active bladder syndrome OAB) or mixed incontinence?1
Has the patient had a vaginal examination to exclude:
a any pelvic masses 2
b urogenital prolapse3
c a fistula3
d faecal loading4
e urogenital atrophy5
Has an abdominal or bimanual examination confirmed there is no palpable
bladder after voiding? 3
Has urinalysis been performed to exclude?
a macroscopic haematuria6
b microscopic haematuria6
c UTI7
d recurrent or persisting UTI3
Have lifestyle measures been discussed? 1
Have appropriate initial conservative treatments been tried?
Three months of Pelvic floor exercises, (some patients may benefit from
community incontinence nurse supervision),
bladder training
antimuscarinic drugs such as oxybutynin for 6 weeks1
Does the patient need to be referred because of one of the following:
a treatment for their incontinence has failed?3
1
582726463
Review date: December 2013
Yes / No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
9.
b persisting bladder or urethral pain?3
c previous pelvic cancer surgery or pelvic radiation therapy?3
d a suspected neurological cause of the urinary symptom? 8
e associated faecal incontinence? 9
Reason for referring if answering ‘No’ to any of above:
Information required for referral
Medical history &
examination
Problem Table
Allergies
Allergy Table
Medications
Medication Table
GP comments (including any other relevant information)
582726463
Review date: December 2013
Yes
No