Gloucestershire Health Community
Spinal Referrals
This form is to be used in conjunction with Choose and Book for all spinal referrals to an
interface service.
Patient Details
Referrer details
Surname:
Referring GP:
Forename:
Usual GP:
Address:
Address:
Postcode:
Postcode:
Home tel:
Tel:
Daytime tel:
Fax:
Date of Birth
NHS Number:
Reason for referral (referral letter):
Please indicate any relevant history:
1. Has the patient had an MR scan? If yes, and it is not on the PACS system please
ensure that the report and the disc is available for their appointment.
2. Has the patient had a course of non-steroidal anti-inflammatory drugs or pain killers
for this problem?
3. Have you referred the patient for Physiotherapy, or an equivalent comprehensive
treatment package? If not, please consider this before referral to a specialist
interface service.
Yes
Please indicate your provisional diagnostic triage
4. a) Back/ neck Pain :-
e.g. non-specific, mechanical, degenerative, facet OA
5. b) Leg / Arm symptoms:- e.g. nerve root, radiculopathy, sciatica, neurogenic
claudication, stenosis
6. c) Possibly serious:-e.g. trauma/fracture, malignancy/tumour/myeloma, infection
7. d) Emergency: e.g. Cauda Equina Syndrome, cord compression, violent trauma,
infection
(please send straight to the Emergency Department)
8. Does this referral follow the health community referral guidelines & commissioning
statements?
9. Does the patient have psychological distress or a mental health problem that is
relevant to this presentation? If yes, please give a summary below.
10. Is the patient “Ready, Fit, and Willing” to have surgery within 18 weeks?
11. Is the patient’s blood pressure within normal limits/controlled limits (<180/95)? If not
please treat and then refer.
12. Is the patient’s BMI higher than 40? Please refer the patient for weight management
advice before referral as weight reduction may improve symptoms and reduce the
risk of peri-operative complications
Please record the patient/s smoking status below. Patients who smoke should be encouraged to
attend a smoking cessation course prior to surgery
13. Please indicate what the patient’s expectations are from the planned assessment
14. Other significant information to be recorded:
Pain Score:
BMI:
BP:
Back:
Leg:
GAD7 Score:
Smoker: Yes
/ No
PHQ9 Score:
Any further information:
Current consultation:
Active problems:
Medical history
Repeat prescriptions:
Drug allergies
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