Adult MSK Service
Referral Proforma
Please complete BOTH sides of this form in FULL and fax to Adult MSK Service.
Fax: 020 8319 8560
Patient Details
Surname:
DOB:
Tel: 020 8331 3250
First name:
NHS No:
Daytime Telephone
Gender:
Ethnicity:
M
F
Patient aware of the referral?
Y
Interpreter required?
First Language
Y
N
E-Mail Address
Home Telephone /Mobile No
Address
NB: Please note we have a text message appointment
reminder service. Unless opted out, patients will
automatically receive text reminders.
Opt Out
Post Code
Patient referred to this service before?
Transport required?
Y
Y
Referring Details
Referring GP
Practice Address
N
N
N
Date of Referral
Telephone
Fax
Post Code
Please note: We do NOT accept referrals for
LOWER BACK PAIN (acute only <6/52) – Please refer to Low Back Pain Physiotherapy at Queen Elizabeth.
PAEDIATRICS (under 16 years of age) – Please refer to Children’s Physiotherapy department at Goldie Leigh.
Referral details
History of current problem:
Duration of problem:
Objective examination findings/ tests:
Diagnosis:
Version 3 - Feb 2016
Adult MSK Service | ACHS
Name:
NHS No:
Social History
Employed?
Y
N
Occupation:
Living alone?
Y
N
Housebound?
Y
N
Main carer for dependents? Y
N
Currently off work?
Duration off work:
Visually Impaired?
Hearing impaired?
Other?
Is problem affecting sleep?
Is problem affecting recreation?
Y
N
Previously seen (for this problem) by:
Consultant? Y
N
Physiotherapist? Y
N
Other? Y
Y
N
Y
Y
N
N
Y
N
N
If yes to any of the above, please provide details:
Previous relevant treatment for this condition:
Investigations relevant to this referral (eg X-ray/ MRI/ Blood):
ESR:
Past medical history:
CRP:
History of depression? Y
N
Alk Phos:
Treatment:
Current medication:
Please tick if any of the following apply:
‘Red Flags’
Major trauma
Age >50 or <20
History of carcinoma
History of prolonged steroid use
Signs suggestive of myelopathy
Two or more reflexes lost
History of prolonged steroid use
Recent bacterial infection
I V Drug use
Tendency to low mood
Fear avoidance behaviour
Is there any litigation concerning this presentation?
Version 3 - Feb 2016
Minor trauma in elderly or osteoporotic
Patient unwell, fever, chills or weight loss
Severe or progressive sensory alteration or weakness
Signs suggestive of vascular insufficiency (Neck)
Abnormal blood tests
Immunosuppressed
Pain worsening at night
‘Yellow Flags’
Health anxieties (belief that pain is harmful)
Expecting passive treatment
Y
N
Adult MSK Service | ACHS