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

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* 1. Patient Details

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* 2. D.O.B

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* 3. Gender identity:

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

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* 5. Name of GP

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* 6. GP Surgery 

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* 7. GP Surgery Address

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* 8. GP Surgery Telephone 

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* 9. Name of Case Manager?

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* 10. Name of Solicitor

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* 11. Name of Prosthetic centre?

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* 12. Are you on Active Treatment?

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* 13. Reason for referral?

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* 14. How did you find out about us?

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* 15. Amputation (if applicable) level or condition:

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* 16. Cause:

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

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* 18. Smoker?

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* 19. Diabetic

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* 20. Visual Impairment

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* 21. Hearing Impairment

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* 22. Unexplained weight loss

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* 23. Angina

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* 24. Rheumatic fever

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* 25. Heart murmur

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* 26. Blood pressure

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* 27. Bleeding/anticoagulant treatment

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* 28. Are you taking Steroids?

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* 29. Bronchitis

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* 30. HIV/Hepatitis/MRSA

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* 31. Alcohol

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* 32. Kidney disease

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* 33. Epileptic

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* 34. Liver disease

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* 35. Pregnant

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* 36. Heart attack

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* 37. Irregular heart beat

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* 38. Pace maker

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* 39. DVT or PE

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* 40. TIA / Stroke?

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* 41. TB

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* 42. Asthma

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* 43. Other

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

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* 45. 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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* 46. Allergies or objections (Medication, animal products and materials, e.g. nickel or glues)

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* 47. Do you require mobility equipment to get in and out of a chair? (for example, a hoist, sliding board, pivot table or walking frame)

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* 48. Any history of anxiety or depression

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* 49. Are you a Driver

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* 50. Please state any religious preferences or requirements

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* 51. 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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