Musculoskeletal Clinician Referral Form

This referral form should not be used for referral into Core Physio. Please use the relevant self-referral form to access this service.For information please see Musculoskeletal folder on G-Care https://g-care.glos.nhs.uk/pathway/114/resource/3Please complete this form fully to enable the service to select the correct course of treatment.

Referrer Details Patient DetailsName:       Name:      GP Organisation:      Address:       Address:       Gender:      

NHS No:      Tel No:      

Email GP Practice     

Home Tel:       Email:      

Translator required: Yes/No Language (please state):      Transport required: Yes/No

Clinical details.

Suggested Urgency: Urgent Routine

Reason for referral/ suspected diagnosis: please include pain score, body part, signs and symptoms     

History of presenting condition: e.g. mechanism of injury, duration of onset, previous surgery etc.      

Any co-morbidities that the receiving service should be aware of including mental health issues, conditions which may impact on management or operative risk:      

Has the patient had comprehensive conservative management for this condition (as per G-Care guidance).Physio Podiatry Surgery Other (please state)

Has the patient had surgery or other secondary care intervention for this condition (e.g rheumatology or pain clinic) Yes No

If yes, please detail:

If the patient had surgery, please indicate:

Name of surgeon:      

Where the surgery was carried out:      

Date of surgery:      

Please attach any relevant clinic correspondence

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What investigations has the patient had associated with this referral? (please ensure the imaging/report is attached X-Ray, Blood Tests, Neurophysiology, MRI Private, MRI NHS, Other

     List MRI location and detail of “Other” investigations below      If the patient had surgery, please indicate:

Investigation:      

Where investigation carried out:      

Date of investigation:      

Factors to consider including social factors

(e.g sleep disturbance, has the patient been off work, is the patient a sole carer)

     

Was the problem sustained as a direct result of military service? Yes No

Other Information (Please ensure readings are current. This enables the service to offer full choice to the patient if onward referral is required)

Reading Automatic Data Date of Latest Reading

Patient’s weight Date:      

Patient’s BMI       Date:      

Patient’s BP       Date:      

Narrative of referral letter / additional information if required (If this form is fully completed no further information is required):

     

Medication     

Medical History     

Allergies     

Smoking Status:      

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