Female Bladder and Bowel Specialist Referral Form
Please fax completed form to 01895 625 268 or Post to: Contact Centre Team, Kirk House, 97-109 High Street, Yiewsley,
Middlesex UB7 7HJ Tel Number: 01895 486 127
Patient Details:
Name:
Address:
Date of Referral:
NHS No:
D.O.B:
Gender:
Tel no (home):
Tel no (mobile):
Ethnicity: << Select >>
Is an interpreter required? Yes
If yes, which language?
Post code:
Does the patient have a learning disability?
Yes No
Don’t Know
If yes, are any adjustments required?
GP Details:
Surgery Name and Address:
No
GP’s name:
Tel no:
Fax no:
Post code:
Referrers Details (if different from GP):
Name:
Address:
Role:
Tel No:
Fax No:
Obstetric History
Symptoms
Urinary Frequency
Yes
No
Instrumental deliveries:
Urinary Urgency
Yes
No
No of Births:
Nocturia
Yes
No
Caesarean Sections:
Urge Incontinence
Yes
No
Given birth in the last year?
Yes
No
Stress Incontinence
Yes
No
Urinary Tract Infection in the last 12
months? (attach reports)
Yes
No
Duration of symptoms?
Reason for referral:
Bladder Scan
Faecal incontinence
Constipation
Intermittent self-catheterisation
Urinary incontinence
Over active bladder
TWOC at home
Relevant Past Medical History:
Medications:
Any allergies:
Is the patient housebound? Yes
No
Can the patient attend a clinic appointment? Yes
No
Clinical Findings/ Recent Blood Tests/ Urine Tests
PV:
Abdo Exam:
DRE:
MSU:
h t t p :/ / w w w . c nw l . n h s . u k
U&E’s :
Version: Female Bladder and Bowel 3.12.13