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Long Covid Service
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Referrals
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Long covid referral form
Long covid referral form
Long Covid Service assessment hub Referral form
Date of referral
(Required)
Day
Month
Year
Does the patient have mental capacity to agree to this referral?
(Required)
Yes
No
This referral has been discussed with the patient and the patient consents to relevant information being shared with the service provider. Patient consent will include provider access to Summary Care Records. If consent not obtained, please provide further details: Does the clinician have consent to discuss with patient’s relative?
(Required)
Yes
No
If yes, state relative’s name and number (next of kin / main carer)
(Required)
Patient details
Title
(Required)
First name
(Required)
Last name
(Required)
NHS number
(Required)
Date of birth
(Required)
Day
Month
Year
Age
(Required)
Gender
(Required)
Home address
(Required)
City/Town
(Required)
Postcode
(Required)
Telephone
(Required)
Voicemails can be left?
(Required)
Yes
No
Ethnicity
(Required)
Languages
(Required)
Interpreter required?
(Required)
Yes
No
Does the patient have hearing issues?
(Required)
Yes
No
Smoking status
(Required)
Allergies
(Required)
Any other risk factors/special circumstances the team need to be aware of
Covid-19 Status
Suspected covid-19
Date of onset of symptoms
(Required)
Day
Month
Year
Duration of symptoms
(Required)
Test(s) result
(Required)
Positive
Negative
Brief description of initial covid-19 symptoms
(Required)
Management (please send ALL relevant information on care)
(Required)
Home
A&E
Hospital admission
ITU
Outpatient clinic
Other
Other (please state)
(Required)
Investigation already completed (Please send results). Clinically relevant investigations required at least 12 weeks post covid-19 infection
(Required)
Echo
CT/CTPA
Other
Other (please state)
(Required)
The below are mandatory for referral acceptance
Sp02
(Required)
BP
(Required)
RR
(Required)
HR
(Required)
Temp
(Required)
Bloods
(Required)
FBC
U&Es
LFTs
CRP
CK
Haematinics
TSH
HBA1C
Calcium
BNP
Bloods normal
(Required)
Yes
No
Bloods at least 4 weeks post covid-19 infection
(Required)
Yes
No
ECG available
(Required)
Yes
No
ECG performed by Community Cardiology
(Required)
Yes
No
Date ECG performed
(Required)
Day
Month
Year
ECG performed at GP Practice/other provider
(Required)
Yes
No
Date ECG performed
(Required)
Day
Month
Year
CXR available
(Required)
Yes
No
CXR requested
(Required)
Yes
No
Date CXR requested
(Required)
Day
Month
Year
Reason for referral
(Required)
Cough (not present pre-covid)
Shortness of breath (not present pre-covid)
Fatigue (not present pre-covid)
Chest Pain (not present pre-covid)
Pain (not present pre-covid)
Swallowing issues (not present pre-covid)
Weight loss (not present pre-covid)
Uncontrolled diabetes (not an issue pre-covid)
Mobility Issues (not present pre-covid)
Neurological Issues (not present pre-covid)
Dizziness (not present pre-covid)
Sensory issues (not present pre-covid)
Gynaecological issues (not present pre-covid)
Endocrinal issues (not present pre-covid)
Gastric issues (not present pre-covid)
Memory/cognitive (not present pre-covid)
Anxiety (not present pre-covid)
Low mood (not present pre-covid)
Sleep issues (not present pre-covid)
Pressure ulcers/Skin issues
Other issue (not present pre-covid)
Other (please specify)
(Required)
Has Ischaemic Heart Disease/Pulmonary Embolism been excluded?
(Required)
Yes
No
Please give a brief outline of the ongoing problems and what has been tried so far
By yourself
(Required)
By the patient
(Required)
Were any of the symptoms above present prior to their covid-19 illness?
(Required)
Yes
No
If yes please state
(Required)
Is the patient under the care of any other services post covid-19?
(Required)
Yes
No
If yes please state
(Required)
What does the patient want from the service?
(Required)
Referrer's details
Name
(Required)
Profession
(Required)
Organisation/practice code
(Required)
Telephone
(Required)
GP practice
(Required)
GP practice contact number
(Required)
GP practice alternative contact number
(Required)
GP practice email address
(Required)
GP/Referrer signature
(Required)
Date
(Required)
Day
Month
Year
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