King S Neurosurgical Rapid Access Referrals

KHP – Skull Base MDT Proforma

PLEASE ANSWER ALL QUESTIONS ON BOTH PAGES.

When complete please email to [email protected]

Patients Name: Referring Consultant’s Name:

Patients Address: Referring Hospital:

NHS Number:

GP Name and DOB Title: Address Hospital Date of number Referral:

CLINICAL QUESTION / REASON FOR REVIEW:

HISTORY OF PRESENTING COMPLAINT: (Date of admission/ clinic)

CLINICAL FINDINGS: (Please include a brief report or email reports with pro-forma)

MANAGMENT (if any):

PAST MEDICAL HISTORY:

CURRENT MEDICATIONS: (Including information on anti-coagulant medication, if stopped when?)

CURRENT WHO PERFORMANCE STATUS – Asymptomatic (Fully active, able to carry on all pre-disease activities without 0 restriction) Symptomatic but completely ambulatory (Restricted in physically strenuous 1 activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work) 2 Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50%

King’s Skull Base MDT referral pro forma 1 of waking hours) Symptomatic, >50% in bed, but not bedbound (Capable of only limited self- 3 care, confined to bed or chair 50% or more of waking hours) Bedbound (Completely disabled. Cannot carry on any self-care. Totally 4 confined to bed or chair) 5 Death

INVESTIGATION RESULTS

CT Head Yes No Dates:

MRI Head Yes No Scan Location: Dates:

Other Dates: imaging: Yes No

Audiometry Yes No (Please Dates: attach)

Histology Yes No Dates:

Print Name: Date:

King’s Skull Base MDT referral pro forma 2