Community Respiratory Service Referral
Lyng Centre for Health and Social Care
Phone: 0121 507 2664, Option 4
Fax: 0121 612 2031
Monday-Friday 8:00am-8:00pm and Saturday& Sunday 8.30am-4.30pm
Name:
D.O.B:
Address:
Phone:
NHS No:
Mobile:
If Unable to speak English please state Language and include an alternative person to contact and
telephone:
Respiratory Diagnosis:
COPD
Asthma
Bronchiectasis
Interstitial Lung Disease
Other Conditions / Medical History:
Relevant Investigations and Results (e.g. CXR, Arterial Blood Gas results, Spirometry, FBC)
Current Medications:
Referred for:
Assessment and treatment requested
Routine
Urgent
Dietetic Advice
(Please include a copy of the community Nutrition Screening Tool)
Pulmonary Rehabilitation
Have you discussed Pulmonary Rehabilitation
Yes
No
Oxygen Assessment
(Please include latest Spirometry Results and Spo2 on room air)
Management of low level mental health problems (anxiety) related to their lung condition
Occupational Therapy Assessment
GP Name:
GP Address:
Referring Health Professional : AA Team
Other……………………………………………
Name…………….………………………… Signature ………………………………………
Phone: …………………. Fax: …………………. Email: ……………………………………