MSK REFERRAL FORM
PLEASE NOTE: Patients with symptoms of cauda equina compromise should go for acute orthopaedic admission agreed over the phone and NOT the Spine Service. This referral form EXCLUDES referrals for fracture clinic, urgent A&E referrals and suspected cancer 2WW

Referral Date	Long date letter merged	NHS No	NHS Number	BMI		Gender	Gen der	
Urgent referral		If urgent please state reason		
Patient Full Name	Full Name	DOB	Date of Birth	Referring GP Name	Usual GP Full Name	
Registered GP Practice	Organisation Name Organisation Full Address (single line)	
Patient Address	Home Full Address (single line)	
E-mail	Patient E-mail Address	Pref. Tel.	Patient Home Telephone	
Contact Number	Patient Home Telephone / Patient Mobile Telephone	Consent to leave message?		
Ambulance transport?		Details		
Occupation		Interpreter Required?		Which language?		
Patient OFF WORK due to condition?			If yes, how long for?		
ANATOMICAL SITE: Knee		Hip		Hand&Wrist		Foot&Ankle		Pain		Spine		
Shoulder &Elbow		Rheumatology		If requesting DIRECT ACCESS PHYSIO please tick this box		
Please give a brief history and reason for referral (date of onset, comorbidities etc.)
Please note that PMH and medications will auto-populate from your clinical system into the bottom of this form.	SYMPTOM DISTRIBUTION (Please mark on chart or drag and drop the symbols)
PAIN:	NUMBNESS:
PINS & NEEDLES:	SWELLING:	

	
Previous treatment: (Successful or not including physiotherapy, osteopathy etc.)	Previous investigation: (Please attach reports)	
		
Any Red Flags? Please list in the blank box below:		
	
Please note that Red Flags include:	Immunosuppressed (other than steroids)	Hx of serious pathology	
Unexplained weight loss (> 10% body weight in last 3-6/12)	Severe, unremitting night pain	Gait disturbance	
Progressive weakness and/or sensory loss	Rapidly worsening neurological
symptoms	Hx of systemic illness	
Additional details:	
Medication
Medication

Medical History (Active Significant, Active Minor, Past Significant)
Problems

Allergies
Allergies

PLEASE ATTACH ALL REQUIRED REPORTS, PREVIOUS CORRESPONDENCE AND ANY FURTHER INFORMATION REQUIRED