Long Covid SPA/Clinic Referral Form
New Friends Hall, Heath House Lane, Stapleton, Bristol BS16 1EQ
TEL: 0117 9617159 	Email: Sirona.longcovid@nhs.net

Inclusion criteria	Exclusion criteria	
Diagnosis of long covid (>12 weeks duration)	Symptoms new and suggestive of other pathology – please assess for this before referral	

Date of referral: Short date letter merged 

Patient Details: 

NHS No: NHS Number 
Surname: Surname 
Forename: Given Name 
DOB: Date of Birth 
M/F: Gender 
Telephone Number 
H:Patient Home Telephone 
M: Patient Mobile Telephone 
W: Patient Work Telephone
Address: Home Full Address (stacked) 
Communication needs:      

Transport Required: No  Yes 

Is there any possible risk to staff seeing this patient in clinic/at home?      

Clinical Details 

Date of COVID diagnosis? Single Code Entry: Confirmed 2019-nCoV (novel coronavirus) infection...  

Primary persistent symptoms: 

Consultations 

     

Medical history: 

Are there any clinical contraindications to this person engaging with a movement/exercise as part of their rehabilitation if clinically indicated? (please note, graded exercise is not recommended for people living with post-exertional symptoms). 

Problems 

Medication 

Allergies 

BMI 

Blood Pressure 

Smoking 

Alcohol Consumption

Has the patient been referred to any other service for this condition?      

Clinical Investigations completed 
Mandatory: Bloods: FBC /TSH / HbA1c/ U&E / LFT/ CRP / TTG antibodies / calcium / creatinine kinase)
Others: (Cxr/CT/Echo/ECG etc)

Please note that referrals without up-to-date bloods will be rejected and returned to the referrer.

FBC	Single Code Entry: FBC - full blood count...	
HbA1c	Single Code Entry: Haemoglobin A1c level	
TSH	Single Code Entry: Serum TSH (thyroid stimulating hormone) level...	
U&E	Single Code Entry: Urea and electrolytes level...	
LFT	Single Code Entry: Liver function test...	
CRP	Single Code Entry: Serum CRP (C reactive protein) level	
TTG	Single Code Entry: Tissue transglutaminase IgG level	
Calcium	Single Code Entry: Serum calcium level	
Creatinine 	Single Code Entry: Plasma creatinine kinase MB isoenzyme level	

O2 sats	Single Code Entry: Blood oxygen saturation	
Sit/Stand or 40-step test 	Single Code Entry: 1-minute sit-to-stand test...	
Chest x-ray	Single Code Entry: Standard chest X-ray normal...	
D-dimer	Single Code Entry: D-dimer level	
FVC/spirometry	Single Code Entry: Forced vital capacity...	
ECG	Single Code Entry: Electrocardiogram finding	
Echocardiogram	Single Code Entry: Echocardiogram normal...	
NT-proBNP	Single Code Entry: N-terminal pro-B-type natriuretic peptide	

Referral Details 

Name:          
Signature:        
Designation:        
GP Name: Usual GP Full Name 
Consultant:       
GP Address & Tel No: Organisation Name 
Organisation Full Address (stacked) 
Organisation Telephone Number 

Office use only:

Date received:	Triage: