Referrer Details

Referrer Name *

Please state what type of FCP you are. *

GP Practice *

Referral Date *

Patient Details

Patient Name *

Patient Date of Birth *

Address *

NHS Number *

Contact Details *

Referral Details

Presenting Complaint

Please consider site, pain, neural symptoms etc:
Where is the pain -describe area of body affected – any radiation of pain?
Is it constant or intermittent?
Any pins and needles or numbness?
Any weakness?

Presenting Complaint *

History of Present Condition

Please consider onset, evolution, pain characteristics, associated features etc:
When did symptoms start?
Was there any injury to the area, if so how long ago?

History of the Present Condition *

Previous Medical / Surgical History

Please provide a pertinent medical Hx - a summary not a huge list

Previous Medical / Surgical History *

Drugs/Allergies *

Medication

Please provide a summary, not a huge list.

Medication *

Height *

Weight *

BP *

Current BMI Kg/m² *

Smoking Status *

Referral Next Steps

Please select all Expectations of this Referral *

MSK Appointment Pain Management Pod Surgery

Ortho Appointment Hand Surgery

PLEASE REMEMBER ALL URGENT & POTENTIAL RED FLAG CASES SHOULD BE REFERRED AS ALWAYS DIRECTLY TO ORTHOPAEDICS
(< 18, Cauda Equina, Fracture, Tumours, Sepsis, Inflammatory Pathology, Surgical Complications)

*NB Onward Referral to orthopaedics will require current height, weight, BMI, BP, smoking status and patient understanding of referral outcome.
** Please Consider Keele STaRT back score for pain management referrals

Have you considered red flag / malignant conditions? *

Yes

MSK Hub Referral Form