Patient details

Name *

Date of Birth *

Address *

Contact Number *

Next of Kin *

Overseas visitor *

Yes

Patient registered at a GP surgery with Kirklees? *

Yes

Patients primary spoken language? *

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

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 *

Is the patient able to communicate easily? *

Yes

If NO, what is the communication difficulty? *

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

Please detail any potential differential diagnosis that may be contributing to the patients presenting symptoms

Does the patient have palliative and or End of Life Care Needs? *

Yes

Investigations

Abdominal Examination *

Yes

Abdominal Examination - Clinical Findings *

Rectal Examination *

Yes

Rectal Examination - Clinical Findings *

Pathology Investigations *

Yes

Pathology Investigations - Clinical Findings *

Ultrasound Imaging *

Yes

Ultrasound Imaging - Clinical Findings *

Vaginal Examination *

Yes

Vaginal Examination - Clinical Findings *

Other *

Yes

Other - Clinical Findings *

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 *

Adults Continence EMIS GP'S ONLY