Download Patient Details - Sheffield PRESS Portal

Careplus Physiotherapy Referral Form
Patient Details:
Male
Name:
Female
D.O.B:
NHS No.
Patients Address including postcode:
Home Tel No.:
Work No:
Translator required : Yes
No
Mobile No:
Email:
Language/dialect:
Transport required Yes
GP Name & Address:
(see PCT policy)
Practice Stamp:
Urgency of referral
Urgent (2 weeks)
Type of referral
No
Physio
Routine (4 weeks)
Specialist Pathway Team
Not able to advise
(access to diagnostics, onward referral and
injections)
Reason for referral: (Clinical history, duration and severity of symptoms:- comments)
First episode
Flare up
First line management by GP
Previous Treatment
Exclusion Red flags ;- Suspected malignancy, infection, fracture or dislocation, significant worsening neurology or cauda equina symptoms. (If
suspected, patient needs secondary care referral or GP investigation. Do not use this form for patients requiring admission emergency
treatment or cancer fast track.)
Please complete additional information below to assist the triage process.
Knee referrals:
Shoulder referrals:
Previous investigations (please attach results and relevant
letters)
History of significant trauma
History of significant trauma
Immediate swelling
History of intermittent locking
X-rays
History of locking/giving way on
twisting the knee
Suspected distal biceps rupture
Blood Test
Recurrent dislocation/subluxation
Yellow Flags e.g. catastrophising behaviour, fear of
movement, work related issues, emotional issues
PMH
Signature of refer:
Other: (e.g. MRI/US)
Previous Pain Clinic attendance
Drug History inc. current pain
management (please attach printout if
necessary)
Print Name:
BMI
Date:
Please refer via Choose and Book or fax form to 01709 424062
BP