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

Vale of York / NHS
Clinical Commissioning Group

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

Patient Details

Patient Name / TitleForenameSurname
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

NOKNext of kinNext of kin's addressNext of kin's telephoneNext 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

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

Service Relevant Details
Patient NameTitleForenameSurname
Date of BirthDate of birth
NHS Number NHS number

Reason for ReferralType dictated text here

Patient must have confirmed Respiratory Diagnosis of COPD

HAD score

MRC score

Previous pulmonary rehab Date

Investigations (if available)

Spirometry date

FEV1

FVC

FEV1%

SpO2score

Generic Patient Clinical Details

Patient Name / TitleForenameSurname
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)

For Office Use
Date referral received
Accepted / Rejected
Venue of 1st assessment and date
York Community Clinic / Selby Hospital

Version 1.0 15/8/12 SystmOne