Referral Form for Hips, Knees and Shoulder Surgery

REFERRAL FORM FOR HIPS, KNEES AND SHOULDER SURGERY

Dear Doctor, / Referral Date: System Date
Trauma and Orthopaedics / Referral For
Hips
Knees
Shoulders
Out Patients Booking Department
Sandwell & West Birmingham Hospitals NHS trust
PATIENT DETAILS / GP DETAILS
Forename: / Forenames / Referring GP: / Registered GP
Surname: / Surname / Registered GP: / Registered GP
Date of Birth: / DOB / Practice: / Practice Name
Practice Address List
NHS No: / NHS Number
Hosp No (if known):
Gender:
Ethnicity / Ethnic Origin / Telephone: / Practice Main Telephone
Address: / Patient Address List / Fax:
Practice Code:
Home Tel No: Home Telephone Mobile Tel No: Work Tel No:
Any special needs? Yes No If yes, which
Interpreter required?Yes No If yes, please specify language
Clinical Details – (Please type in or Insert relevant consultations)
Please provide Oxford scores if possible :
Click for hip score
Click for knee score
Click for shoulder score
Has the patient agreed to surgery if it is considered appropriate? Yes No
Has the patient had
Physiotherapy Yes No
Injection Yes No
If yes to the above questions, please provide further details if possible?
Hip Replacement / Knee Replacement / Shoulder replacement leaflet given Yes No
Patient’s BMI: (should be less than 35 for Knees and less than 40 for Hip)
Has the patient been on a known weight loss management programme in the last six months?
Yes No
If the patient is being considered for surgery, then are all known co-morbidities controlled and stable? Yes No
e.g. Is the patient’s HB > 10?
Is the diabetes controlled?
Does the patient have stable cardio-respiratory disease?
Relevant Past Medical History:
Current Medication:
Medication Table
Known Drug Allergies or Adverse Effects:
Allergy Table
Does the patient have any special/social circumstances or needs (e.g. hearing, visual, Mental Health, or mobility impairment) Yes No If yes please detail.
Does the patient need home arrangements/ support in place after discharge e.g. if living alone?
Yes No
If yes, has this been discussed with the patient and carers? Yes No

Advice and guidance is available to GP’s by calling the following telephone numbers:-

City Fracture Clinic: 0121 507 4297

Sandwell Fracture Clinic: 0121 507 3120

Or by phoning the main hospital switchboard and bleeping 5153 (Sandwell) or 5019 (City) Specialist Registrar on call or by emailing the following Consultants:

and/or Surgical Care Practitioner: .

Copies of the patient information leaflets can be found on the CCG website in the documents section of the members’ area, under the heading ‘FIXED Campaign’.