Sirona Musculoskeletal (MSK) Service Referral Form

This form is mandatory for all referrals to the below services to aid clinical triage.

What service are you referring to? Please click on Hyperlinks to remedy
-	 MSK Interface 
-	 MSK Physiotherapy 
-	 MSK Foot and Ankle

*Please note that you can also refer to NBT or UHBW for MSK Physiotherapy. See Remedy for clinic locations and up-to-date waiting times. 

Patient Details 	
Surname:      	Forenames(s):      	
Patients Address:
     	Contact 
Numbers:	Home:      	
		Mob:      
Email:      	
	Patient gives consent for: 
Answer machine message 
Message to be left with family member 
Video call 
Text messages 
Emails 	

NHS No:      	Date of Birth:      	
Date of Referral:      	Gender:      	Ethnicity:      	
Special needs of patient: Are there any issues that we should be aware of regarding patient communication

 Interpreter      

 Disability access      

 Carer support      

Other      
	
Staff Safety: Please give details of any known risks to staff and/or other service users regarding this patient:
     

	

Referrer Details	
Referring Clinician:      	Practice Address:
     

	
Profession:      		
Telephone:      		

MSK Referral Information	
Provisional Diagnosis:      

	
Duration of present condition:
 0-6 weeks   6-12 weeks   3-6 months   6 months + 	

Please provide clinical details of the present MSK condition, and other relevant history, investigations, treatment to date: 
     

	

Is the patient currently: 
 Off work due to this condition (please state how long)?      
 Unable to fulfil caring responsibilities?      
 Losing independence?      
 Risk of falls?      	
Does the patient have a specific expectation regarding intervention or treatment?
 Yes	 No 	Comment      	
Keele STarT Back Screening Tool  (complete for all patients with lower back pain)
Score: [free text]
 Low             Medium            High   	
Conservative Management to date: (please add details and dates where possible)	
                                                
 Activity modification      
 Weight loss                  
 Smoking cessation      
 Exercise                       
 Analgesia                    
 NSAIDS                     
 Physiotherapy      
 Podiatry/Orthotics         
 Injections      	
 Walking Aid      	
 Splint/Brace      	
Other …..      
	
Relevant Imaging and/or Investigations:		
                                                      
 Blood tests Date:                        Location:      
 X Ray         Date:                        Location:      		
 USS           Date:                        Location:      
 MRI            Date:                        Location:      	
 NCS           Date:                        Location:      	
 DEXA         Date:                        Location:      	
Other …..      

Secondary Care Referrals 
Is re-direction onto secondary care from triage anticipated?          Yes       No
If so, please consider the relevant BNSSG INNF Policies:
Name of INNF Policy:         N/A
Conservative Measures: Please add above 
Pain Levels (Please use matrix on relevant policy) Slight  Moderate   Intense  Severe    N/A
Functional Deficit (Please use matrix on relevant policy)  Minor       Moderate       Severe    N/A
Fixed Flexion Deformity (Dupuytrens/Trigger Finger Policies Only) Yes  No Degrees      
 N/A

Medical History:

Has the patient previously been identified as having high anaesthetic risk?         Yes       No