Please complete as fully as possible (not all sections will be relevant)

Patient Details

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* 1. Patient Details

Next of Kin (Name and Telephone Contact)

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* 2. Next of Kin (Name and Telephone Contact)

Name of Case Manager?

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* 3. Name of Case Manager?

Name of Solicitor

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* 4. Name of Solicitor

Name of Prosthetic centre?

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* 5. Name of Prosthetic centre?

Are you on Active Treatment?

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* 6. Are you on Active Treatment?

Reason for referral?

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* 7. Reason for referral?

How did you find out about us?

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* 8. How did you find out about us?

Medical History - Describe briefly the background to your referral

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* 9. Medical History - Describe briefly the background to your referral

Smoker?

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* 10. Smoker?

Diabetic

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* 11. Diabetic

Visual Impairment

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* 12. Visual Impairment

Hearing Impairment

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* 13. Hearing Impairment

Unexplained weight loss

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* 14. Unexplained weight loss

Angina

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* 15. Angina

Rheumatic fever

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* 16. Rheumatic fever

Heart murmur

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* 17. Heart murmur

Blood pressure

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* 18. Blood pressure

Bleeding/anticoagulant treatment

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* 19. Bleeding/anticoagulant treatment

Are you taking Steroids?

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* 20. Are you taking Steroids?

Bronchitis

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* 21. Bronchitis

HIV/Hepatitis/MRSA

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* 22. HIV/Hepatitis/MRSA

Alcohol

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* 23. Alcohol

Kidney disease

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* 24. Kidney disease

Epileptic

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* 25. Epileptic

Liver disease

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* 26. Liver disease

Pregnant

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* 27. Pregnant

Heart attack

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* 28. Heart attack

Irregular heart beat

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* 29. Irregular heart beat

Pace maker

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* 30. Pace maker

DVT or PE

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* 31. DVT or PE

TIA / Stroke?

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* 32. TIA / Stroke?

TB

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* 33. TB

Asthma

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* 34. Asthma

Other

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* 35. Other

Any surgery, musculoskeletal or orthopaedic injuries? (i.e. bone fractures,muscle injuries,ligament damage)

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* 36. Any surgery, musculoskeletal or orthopaedic injuries? (i.e. bone fractures,muscle injuries,ligament damage)

Current Medication (list all medication including strength of tablet and number taken daily e.g Asprin tablet 75mg 1 per day)

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* 37. Current Medication (list all medication including strength of tablet and number taken daily e.g Asprin tablet 75mg 1 per day)

Allergies  (List all medication and substances e.g. nickel, that causes allergies to you) 

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* 38. Allergies  (List all medication and substances e.g. nickel, that causes allergies to you) 

Any history of anxiety or depression

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* 39. Any history of anxiety or depression

Are you a Driver

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* 40. Are you a Driver

Any Special requirements required to attend appointments?

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* 41. Any Special requirements required to attend appointments?

Thank you. 

When you attend our clinic you will be asked to sign consent forms, to complete your referral.

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