Patient details

Name *

Date of Birth *

Address *

Contact Number *

NHS number *

Next of Kin *

Overseas Visitor? *

Yes

Patient registered at a GP surgery with Kirklees? *

Yes

What is the patient’s main spoken language? *

Is an interpreter needed? *

Yes

Are there any communication needs for this patient or their parent/carer? For example, related to learning disabilities or autism or due to impaired sight/ hearing or any other reason/s. *

Yes

What might be helpful when communicating with this patient or their parent/carer? *

Patient has consented to information sharing? *

Yes

Patient has consented to referral? *

Yes

If patient is unable to consent to the referral, please provide details *

Best interest decision made by (Name) *

Best interest decision made by (Phone Number) *

Referral

Does the patient usually visit their GP Surgery or Hospital Consultant? *

Yes

Are there any risks associated with a home visit? *

Yes

If yes, describe the risks *

Can the patient transfer from bed to chair without assistance? *

Yes

Does the patient require hoisting? *

Yes

If the patient has a door code, state the code *

If a homecare agency visits, state the name of the agency and any relevant contact numbers *

How long has the patient had symptoms for? *

Specific referral details - tick all boxes that apply *

New referral to service Referral from residential home

Re-referral to service

Non Professional Referral (Patient or Carer) - Describe the presenting symptoms *

Leaks urine when coughing or sneezing Has been told they have a prolapse (women only) Bowel incontinence

Has urgency when need to pass urine Constipation Other

Please describe the presenting symptom *

Professional Referral (GP, Consultant, Health Care Professional) - Describe the presenting symptoms *

Stress incontinence Prolapse with associated bladder of bowel dysfunction Pelvic floor dysfunction Neurogenic bladder symptoms that require the teaching of intermittent self-catheterisation

Overactive bladder Any of the above with sexual dysfunction Bowel problems (constipation or incontinence) Neurogenic bladder

If the patient has a long term illness please state *

Please state if the patient has had any surgery in the last 6 months *

If other, please state type of surgery... *

Please state any other additional relevant information *

Referrer details

Referrer name *

Referrer email *

Referrer contact number *

Job title *

Referring from *

Care Home Hospice Self Referral

GP Practice Local Authority

Adults Continence