Living with COPD Referral Form (CBT Respiratory) Page 1 of 3

Vale of York NH S Clinical Commissioning Group

‘Living with COPD’ Referral Form (CBT Respiratory) Page 1 of 3

Patient Details

Patient Name Title Forename Surname Patient Gender Gender Date of Birth Date of birth NHS Number NHS number

Patient Address Patient address house Patient address road Patient address locality Patient address post town Patient address county Patient post code Email Address Home Telephone Patient home telephone number Mobile Telephone Patient mobile telephone number Work Telephone Patient alternate telephone number

NOK Next of kin Next of kin's address Next of kin's telephone Next of kin's mobile telephone

GP Details

Referring GP Sender name Usual GP Usual doctor Registered GP Registered doctor Practice Name Scott Road Medical Centre Practice Address Registered GP address Practice Telephone Registered GP phone number Practice Code Registered GP practice ID

Date of referral Todays date Yes

Return this form to the Community Respiratory Team

By post: Community Respiratory Nurse, Clementhorpe Health Centre, Cherry St, York, YO23 1AP

By fax: 01904 726318

Respiratory Team Telephone Number: 01904 724537

Version 1.0 15/8/12 SystmOne Vale of York NH S Clinical Commissioning Group

Service Relevant Details Patient Name Title Forename Surname Date of Birth Date of birth NHS Number NHS number

Reason for Referral Type dictated text here

Patient must have confirmed Respiratory Diagnosis of COPD

HAD score

MRC score

Previous pulmonary rehab Yes Date

Investigations (if available)

Spirometry date FEV1 FVC FEV1%

SpO2 score

Version 1.0 15/8/12 SystmOne Vale of York NH S Clinical Commissioning Group

Generic Patient Clinical Details

Patient Name Title Forename Surname Date of Birth Date of birth NHS Number NHS number

Summary Problem list Major Active Problems (w/o contents) Minor Active Problems (w/o contents)

Current Repeat Medication List Current Repeat Templates

Allergies & Sensitivities Allergies

Other relevant history (start typing in grey box which will expand as needed)

Acceptance/Exclusion Criteria Acceptance  Completed HAD score  Completed referral form Exclusions For Office Use  Cognitive impairment  Diagnosed severe depression Date referral received

Accepted Rejected

Venue of 1st assessment and date

York Community Clinic Selby Hospital

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