<p> Vale of York NH S Clinical Commissioning Group</p><p>‘Living with COPD’ Referral Form (CBT Respiratory) Page 1 of 3</p><p>Patient Details</p><p>Patient Name Title Forename Surname Patient Gender Gender Date of Birth Date of birth NHS Number NHS number</p><p>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 </p><p>NOK Next of kin Next of kin's address Next of kin's telephone Next of kin's mobile telephone </p><p>GP Details</p><p>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</p><p>Date of referral Todays date Yes</p><p>Return this form to the Community Respiratory Team</p><p>By post: Community Respiratory Nurse, Clementhorpe Health Centre, Cherry St, York, YO23 1AP</p><p>By fax: 01904 726318</p><p>Respiratory Team Telephone Number: 01904 724537</p><p>Version 1.0 15/8/12 SystmOne Vale of York NH S Clinical Commissioning Group</p><p>‘Living with COPD’ Referral Form (CBT Respiratory) Page 2 of 3</p><p>Service Relevant Details Patient Name Title Forename Surname Date of Birth Date of birth NHS Number NHS number</p><p>Reason for Referral Type dictated text here</p><p>Patient must have confirmed Respiratory Diagnosis of COPD </p><p>HAD score </p><p>MRC score </p><p>Previous pulmonary rehab Yes Date </p><p>Investigations (if available)</p><p>Spirometry date FEV1 FVC FEV1% </p><p>SpO2 score </p><p>Version 1.0 15/8/12 SystmOne Vale of York NH S Clinical Commissioning Group</p><p>‘Living with COPD’ Referral Form (CBT Respiratory) Page 3 of 3</p><p>Generic Patient Clinical Details</p><p>Patient Name Title Forename Surname Date of Birth Date of birth NHS Number NHS number</p><p>Summary Problem list Major Active Problems (w/o contents) Minor Active Problems (w/o contents)</p><p>Current Repeat Medication List Current Repeat Templates</p><p>Allergies & Sensitivities Allergies</p><p>Other relevant history (start typing in grey box which will expand as needed) </p><p>Acceptance/Exclusion Criteria Acceptance  Completed HAD score  Completed referral form Exclusions For Office Use  Cognitive impairment  Diagnosed severe depression Date referral received</p><p>Accepted Rejected</p><p>Venue of 1st assessment and date</p><p>York Community Clinic Selby Hospital</p><p>Version 1.0 15/8/12 SystmOne</p>