<p> KHP – Skull Base MDT Proforma</p><p>PLEASE ANSWER ALL QUESTIONS ON BOTH PAGES.</p><p>When complete please email to [email protected] </p><p>Patients Name: Referring Consultant’s Name: </p><p>Patients Address: Referring Hospital: </p><p>NHS Number: </p><p>GP Name and DOB Title: Address Hospital Date of number Referral: </p><p>CLINICAL QUESTION / REASON FOR REVIEW: </p><p>HISTORY OF PRESENTING COMPLAINT: (Date of admission/ clinic)</p><p>CLINICAL FINDINGS: (Please include a brief report or email reports with pro-forma)</p><p>MANAGMENT (if any):</p><p>PAST MEDICAL HISTORY: </p><p>CURRENT MEDICATIONS: (Including information on anti-coagulant medication, if stopped when?)</p><p>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% </p><p>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</p><p>INVESTIGATION RESULTS</p><p>CT Head Yes No Dates: </p><p>MRI Head Yes No Scan Location: Dates: </p><p>Other Dates: imaging: Yes No </p><p>Audiometry Yes No (Please Dates: attach) </p><p>Histology Yes No Dates: </p><p>Print Name: Date: </p><p>King’s Skull Base MDT referral pro forma 2</p>