Criteria

Please note: this form is for patients registered with Greater Huddersfield CCG only

GP Practices in Greater Huddersfield Pulmonary Rehabilitation Service

Referral criteria

• respiratory disease
• independently mobile and no transport required
• must be able to commit to attending Pulmonary Rehabilitation for 16 sessions over 8 weeks
• must be motivated to attend and make changes to their lifestyle
• are happy in a group environment and will actively participate in the programme
• have a MRC score of 3 or greater

Exclusion criteria. Please contact to discuss if required.

• Acute Left Ventricular Failure (LVF)
• Acute cardiac event within last 3 months
• Uncontrolled cardiac arrhythmia/angina
• Cerebral Vascular Accident/neurological incident within last 3 months
• Pulmonary embolus/Deep Vein Thrombosis within last 3 months not receiving treatment
• Abdominal Aortic Aneurysm (AAA) > 5.5cm or any AAA with uncontrolled BP
• Aortic stenosis
• Surgery within 6 weeks
• Acute/current psychotic episode
• Alcoholism affecting life
• Any medical problems preventing exercise or compliance with programme
• Attending other rehab programme

COVID-19

Referrers from acute settings should provide this information to best of their ability. Not doing so can slow the process down considerably.

Date of referral

Date of discharge from hospital

Hospital discharged from

COVID-19 status

Negative

Positive

Date of COVID-19 test

Referrer Details

If contact details are incorrectly input where mandatory the referral cannot be processed

Name *

Date *

Email *

Patient Details

If contact details are incorrectly input where mandatory the referral cannot be processed

Name *

Address *

Telephone *

NHS Number *

Date of Birth *

Mobile Telephone Number *

Overseas visitor? *

Yes

Patient has consented to information sharing? *

Yes

Patient has consented to referral? *

Yes

Communication

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 Condition Information

All questions marked with a * should be answered

Reason for referral/diagnosis *

If not recently recorded in the patient's record, what is the current Medical Research Council Dyspnoea Score Chart (MRC)?

Not troubled by breathlessness except on strenuous exercise Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace Too breathless to leave the house, or breathless when dressing or undressing

Short of breath when hurrying or walking up a slight hill Stops for breath after walking about 100m or after a few minutes on level ground

Oxygen saturations % at time of referral *

Is the patient receiving long term oxygen or ambulatory therapy? *

Yes

What is the prescribed Litres / minute for their oxygen therapy?

Any additional information or comments

What You Need To Do Next

Supporting documents required with this referral

Spirometry result (including print of graphs) Upload file

Chest X-ray report Upload file

For any issues with this referral form please contact Locala Single Point of Contact – 0300 304 5555

Now you have completed this form, please remember to click 'Submit'.