podiatry referral by 6fZpX3Vk


									                                  COMMUNITY PODIATRY REFERRAL FORM
The Sutton & Merton Community Podiatry Service provides clinical care for foot conditions that require treatment
                                  from a registered health care professional
               The Podiatry Service is unable to provide basic foot care or nail cutting services
         Please complete this form in full as incomplete forms will be returned which will delay the referral
                                                PATIENT’S DETAILS
Title:                    Forename(s):                             Surname:
   Male       Female      NHS Number:                              D.O.B:
Address (incl. postcode):
Daytime contact number:                                            Alternative contact number:
Email address:
   White British                    Any other mixed background          Black/ Black British Caribbean
   White Irish                      Chinese                             Black or Black British African
   Any other White                  Asian or Asian British Indian       Any other Black groups
   Mixed:White&Black Caribbean      Asian or Asian British Bangladeshi  Any other ethnic group
   Mixed: White & Black African     Asian or Asian British Pakistani    Declined to state ethnicity
   Mixed: White & Asian             Any other Asian background
                             NEXT OF KIN’S/CARER’S DETAILS (if applicable)
Name:                                                         Relationship to patient:
Daytime contact number:                                       Alternative contact number:
                                                  GP’S DETAILS
Date of referral:                                             GP’s Name:
Contact number:                                               Fax number :
Surgery address:
NHS.net email address:
                                        REFERRER’S DETAILS (if not GP)
Name:                                                         Job title:
Contact number:                                               Fax number :
Signature:                                                    Date of referral:
Email address (safe to send patient details):
                                       GENERAL NEEDS OF THE PATIENT
Are you aware of the patient’s living circumstances?      Alone      Spouse/Partner       Other:
Is the patient housebound?
    Yes, permanently        Yes, temporarily
    No, the patient can attend an outpatient appointment
    No, the patient can attend an outpatient appointment but will need transport
If an interpreter is required, what language is required?
Did patient / carer consent to referral and assessment:     No      Yes, please state reason:

Are you aware of the any social issues that need to be highlighted for this referral?     No         Yes, please
state reason:

Patient /Carer signature (if applicable):
                  (To be completed by GP or other health care professional only)
 Please complete both sections (podiatric need and medical conditions) to enable us to assess your patient’s
                                          foot health requirements.

                        Appointments will only be offered where there is a podiatry need.
What is the patient’s podiatric need?
What is the duration of the condition:
Lesions arising from foot deformity?                                                            Yes     No
Pathological nail (s) e.g. in-growing toenail with inflammation/infection
                                                                                                Yes     No
(excluding fungal nails)
Corn and/or callus                                                                              Yes     No
Open Wound: non-healing, involving subcutaneous tissue                                          Yes     No
Inflammation/infection of foot)                                                                 Yes     No
Musculoskeletal/biomechanical: foot pain due to foot mechanics and gait)                        Yes     No
Verruca: (painful and / or spreading)                                                           Yes     No
                          Peripheral Vascular Disease and Peripheral Neuropathy
Does the patient have signs of Intermittent claudication?                                      Yes     No
Is the patient under the care of a Vascular team?                                              Yes     No
Monophasic pulses & signs & symptoms (cold, cyanotic, mottled)?                                Yes     No
Does the patient have a history of ulceration / amputation of lower limb?                      Yes     No
Does the patient have micro vascular disease (arterial)?                                       Yes     No
Other (please state):

Peripheral Neuropathy: Less than 5/10 monofilament on either foot:                             Yes      No
                                           Medical / Surgical History
Is the patient immuno-compromised / auto-immune disease?                                       Yes       No
Does the patient have diabetes mellitus?                                                       Yes       No
Does the patient have chronic kidney disease stages 3-5?                                       Yes       No
Has this patient been under the Falls Service previously or had a falls assessment?            Yes       No
Other (please state):

Please state if any (please attach EMIS report):

Please return this referral form to the Sutton and Merton Administration Centre:
Email: rmh-tr.smcsadmin@nhs.net                   Fax:020 345 85 888
Address: SMCS Administration Team, PO Box 70926, London, SW19 9FS
Contact number: 0845 567 2000

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