Details

Has the patient consented to this referral (and the sharing of all details included) or is this a Best Interests Decision to refer? *

Yes

Name and phone number of referrer *

Email address of referrer (this must be supplied so we can contact you about the referral) *

Referring from e.g. Hospital (name of hospital and ward) *

Patient title and name *

NHS number *

Date of birth *

Gender *

Address inc postcode *

Please provide relevant POTENTIAL OR ACTUAL safeguarding concerns or issues *

Are there any risks associated with visiting or providing support for this person including challenging behaviours, medication, infection control & Moving and Handling? *

Overseas visitor? *

Yes

What is the patients main spoken language? *

Is an interpreter needed?

Yes

If yes, what language?

Does this patient or their parent/carer have a communication disability? For example, related to learning disabilities or autism or due to impaired sight/hearing or any other reason/s? *

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

Pulmonary Rehabilitation

GP Practices in Greater Huddersfield Pulmonary Rehabilitation Service

Referral Criteria:

confirmed diagnosis of respiratory disease
medically stable with optimised medical therapy for disease severity
motivated to attend and complete the programme (14 sessions over 7 weeks)
MRC score of 3 or more (or MRC2 if functionally limited by disease)

Exclusion criteria:

Unstable angina, uncontrolled heart failure, BP or arrhythmia, MI <6/52, abdominal Aortic Aneurysm (AAA) > 5.5cm, severe aortic stenosis
Neurological, physical or cognitive impairment preventing safe participation in group exercise sessions

Reason for referral/diagnosis *

Oxygen saturations at time of referral (%) *

Is the patient receiving O2 therapy (LTOT or ambulatory) *

Yes

If YES, please state prescription (L/min) *

Hospital admission within the last 4 weeks (for exacerbation or other respiratory -related problem)? *

Yes

Please include Spirometry (with graphs) Upload file

Please provide most recent diagnostic result, including date or please attach Consultant letter below *

Please attach consultant letter here Upload file

For advice either pre or post referral, please contact the Pulm Rehab team on 0300 304 5555

Respiratory - SOUTH ONLY

Please note

This service does not accept referrals with TB.

Home visits if requested are nurse visits and are primarily for education, and interventions in patient’s own homes are limited.

If referring only for oxygen, this needs to go the Home Oxygen Assessment and Review Service - 0800 9160625

What are your expectations from this referral? *

Please list 'all' current medications/drug reactions/allergies

Investigations details - Spiro, chest X-ray etc

Please attach any clinical letters/any other relevant information Upload file

Any additional information relevant to the referral

Respiratory and Pulmonary Rehabilitation