Download Referral form

DYSPHAGIA TEAM FOR ADULTS WITH LEARNING DISABILITIES (DTALD)
REFERRAL FORM
Please complete this form in full, as incomplete forms may be returned, which will delay service
provision.
CLIENT’S DETAILS
Title:
M
F
Forename(s):
Surname:
NHS Number:
D.O.B:
Address (incl. postcode):
Daytime contact number:
Alternative contact number:
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
NEXT OF KIN’S/CARER’S DETAILS (if applicable)
Name:
Relationship to client:
Daytime contact number:
Alternative contact number:
GP’S DETAILS
Date of referral:
GP’s Name:
Contact number:
Fax number :
Surgery address:
NHS.net email address:
REFERRER’S DETAILS (if not GP)
Name:
Job title:
Contact number:
Fax number :
Signature:
Date of referral:
Email address (safe to send client details):
GENERAL NEEDS OF THE CLIENT
If an interpreter is required, what languages are spoken and preferred?
Does the patient have a learning disability?
Can client attend an outpatient clinic?
Yes
Yes
No
No. If no, please state reasons why not:
Did client/carer consent to referral and assessment:
Yes
No, please state reason:
Are you aware of any social issues that need to be highlighted regarding this referral?
No
Yes, please state reason:
Are other teams/disciplines currently involved with this client?
No,
Yes, please specify:
MEDICAL DETAILS OF CLIENT
Please list the client’s relevant medical/surgical history (or attach EMIS report):
Does the client have a diagnosis of learning disability?
Yes (please provide known details).
provide comment on whether client is perceived to have a learning disability): Details:
No (please
Please indicate whether any of the following assessments have been performed previously or recently? (please
tick and attach relevant reports or provide relevant, known details).
chest x-ray
brain imaging (please list specific assessment performed):
Ear Nose and Throat (ENT)
Gastroenterology
Details:
Please comment on any impairment in visual, hearing, or mobility skills, or any relevant, known allergies:
Please list the client’s current medication:
REASON FOR REFERRAL/DIAGNOSIS
Reason for referral: Please provide a summary of related details below, especially if a ‘yes’ response is
given, including duration of difficulties, and attach relevant reports.
No
1
2
3
4
5
6
7
8
9
9.1
10
10.1
Does the client have difficulty swallowing [food] or [drink] ? (please circle what is
difficult to swallow)
Does the client cough [when eating] and/or [drinking]/ and/or [at rest]? (please
circle when coughing is performed)
Does the client experience difficulty swallowing medications?
Does the client experience difficulty managing their saliva?
Has the client had an x-ray of swallowing before: e.g. [Videofluoroscopy] or [Barium
Swallow]? (Please circle assessment performed or leave blank if uncertain).
Does this client have a known diagnosis of gastro-oesophageal reflux disease
(GORD)?
Has the client experienced a choking episode recently or previously? If yes, please
provide details below.
Has the client had recent chest infection/s? (If yes, and if there has been more than
one occasion of chest infection, please provide details below).
Is the client receiving alternative long-term feeding via a [Percutaneous Endoscopic
Gastrostomy (PEG)] or [Radiologically Inserted Gastrostomy (RIG)] feeding tube?
(please circle which tube is inserted).
If PEG feeding is performed, are feeds [partial] or [complete]? (please circle type of
feeding performed)
Has the client recently lost weight? If yes, please state amount
and time period of loss below.
If client has lost weight, has a referral been made to Community Dietetics? If no,
please provide reason/s below.
Yes
No
11
Is the client currently on a modified diet or fluid? (go to question 11.1)
11.1
If yes, please indicate which diet/fluid consistency the client is consuming:
Yes
Foods:
Full diet (no restrictions);
Soft: [chewable] / [fork mashed] - please circle.
Pureed: [textured] / [smooth]- please circle.
Drinks:
Normal (thin);
‘Slightly thick’ (1 scoop of thickening powder per
200ml);
‘Syrup thick’ (2 scoops of thickening powder per 200ml);
‘Custard thick’ (3 scoops of thickening powder per 200ml);
‘Pudding thick’ (more than 3 scoops of thickening powder per 200ml).
11.2 For clients who are on a modified diet, is a [food] or [fluid] consistency being
consumed which has not been recommended? (please circle what is being
consumed against recommendations, and provide details below).
12
Does the client use any special equipment to assist eating or drinking, or to assist
posture? If yes, please provide details below.
Additional information regarding swallowing referral (attach any further information):
What is your perceived urgency of this swallowing referral?
Non urgent;
Urgent
(Note: Leave blank if uncertain). Please state reasons for any referral perceived as urgent:
Please return this referral form to the Merton adult services single point of access (SPA):
Email: [email protected]
Efax: 0300 008 2122
Address: Merton adult services single point of access (SPA), PO Box 70926, London, SW19 9FS
Contact number: 0333 004 7555