FIT CLINIC Source of referral (please ring): REFERRAL FORM For GP Referrals please attach to eRS. For non-GP Referrals please e-mail to the Name of referrer and contact phone number: following address with Fit’ in the title. ‘First Email: stgh-tr.Neuro@nhs.net Tel: 0208 725 4321 SGH Consultant code: __ __ __ GP STAMP( name and address) Date and time of referral: Date__ /__ /__: time __ : __ (24h clock) Patient details For seizures or unclear blackouts where seizures can not be excluded as differential diagnosis (the latter might be referred to Name : arrhythmia clinic, cardiology at same time) Yes No Sex : Above 16 years old? D.O.B. : Address: New onset seizures/blackouts within last 12 month? Latest seizure/blackout within last 3 month? Not started on anti-epileptic drugs? Tel. No.: name: Refer only for rapid access first fit clinic if all above are yes. Carer’s Tel. No.: Sheldon’s Questionnaire (see bottom of form) ≥1 Handed Left / Right Is Hospital transport required? Yes / No Preferred language Type required Car Ambulance Interpreter needed Yes / No Current Drug Therapy: Summary presenting event, past medical history and relevant family history: Witnesses to event(s): PLEASE ASK ANY WITNESS(ES) TO COME WITH PATIENT TO CLINIC; Provide contact details here if this may not be possible:
FIT CLINIC REFERRAL FORM For GP Referrals please attach to eRS. For non-GP Referrals please e-mail to the following address with ‘First Fit’ in the title. Email: stgh-tr.Neuro@nhs.net Tel: 0208 725 4321 Source of referral (please ring): Name of referrer and contact phone number: SGH Consultant code: __ __ __ Date and time of referral: Date__ /__ /__: time __ : __ (24h clock) GP STAMP( name and address) Patient details Name : Sex : D.O.B. : Address: Tel. No.: name: Carer’s Tel. No.: For seizures or unclear blackouts where seizures can not be excluded as differential diagnosis (the latter might be referred to arrhythmia clinic, cardiology at same time) Yes No Above 16 years old? New onset seizures/blackouts within last 12 month? Latest seizure/blackout within last 3 month? Not started on anti-epileptic drugs? Refer only for rapid access first fit clinic if all above are yes. Sheldon’s Questionnaire ≥1 (see bottom of form) Handed Left / Right Preferred language Interpreter needed Yes / No Is Hospital transport required? Yes / No Type required Car Ambulance Summary presenting event, past medical history and relevant family history: Current Drug Therapy: Witnesses to event(s): PLEASE ASK ANY WITNESS(ES) TO COME WITH PATIENT TO CLINIC; Provide contact details here if this may not be possible:
SGH-First-Fit-referral-form-Nov-2018.docx