GU KIDNEY, urinary or sexually transmitted YES NO disease? CNS EPILEPSY, convulsions, neurological YES NO disease? Learning difficulties? YES NO Mental illness/ Psychiatric problems? YES NO Alcohol or Drug addiction (past/present)? YES NO END DIABETES, thyroid, other hormone YES NO disorders? LM Bone or disease? YES NO Skin disease e.g. Eczema, dermatitis? YES NO ALLERGIES (E.g. penicillin, aspirin, YES NO paracetamol, latex, Elastoplast)? Any other diseases or conditions? YES NO Previous operations? YES NO Previous serious illness or admissions to YES NO hospital? Signed by patient/parent/carer: Date:
GU KIDNEY, urinary or sexually transmitted disease? YES NO CNS EPILEPSY, convulsions, neurological disease? YES NO Learning difficulties? YES NO Mental illness/ Psychiatric problems? YES NO Alcohol or Drug addiction (past/present)? YES NO END DIABETES, thyroid, other hormone disorders? YES NO LM Bone or disease? YES NO Skin disease e.g. Eczema, dermatitis? YES NO ALLERGIES (E.g. penicillin, aspirin, paracetamol, latex, Elastoplast)? YES NO Any other diseases or conditions? YES NO Previous operations? YES NO Previous serious illness or admissions to hospital? YES NO Signed by patient/parent/carer: Date:
service-directory-2016-referral-forms-v7.docx