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 Case Manager?

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* 6. Name of Solicitor

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* 7. Name of Prosthetic centre?

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* 8. Are you on Active Treatment?

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* 9. Reason for referral?

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* 10. How did you find out about us?

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

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* 12. Smoker?

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* 13. Diabetic

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* 14. Visual Impairment

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* 15. Hearing Impairment

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* 16. Unexplained weight loss

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* 17. Angina

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* 18. Rheumatic fever

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* 19. Heart murmur

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* 20. Blood pressure

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* 21. Bleeding/anticoagulant treatment

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* 22. Are you taking Steroids?

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* 23. Bronchitis

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* 24. HIV/Hepatitis/MRSA

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* 25. Alcohol

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* 26. Kidney disease

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* 27. Epileptic

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* 28. Liver disease

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* 29. Pregnant

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* 30. Heart attack

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* 31. Irregular heart beat

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* 32. Pace maker

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* 33. DVT or PE

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* 34. TIA / Stroke?

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* 35. TB

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* 36. Asthma

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* 37. Other

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

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

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* 41. Any history of anxiety or depression

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* 42. Are you a Driver

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* 43. Please state any religious preferences or requirements

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* 44. 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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