Reason for Referral/ Current Assessment of Needs: Relevant Past Medical History and Psychiatric History: Current Medication: Insight Does the patient consent to referral? Yes No Has the patient been told diagnosis? Yes No Is the carer aware of the patient’s diagnosis? Yes No Does the patient discuss the illness freely? Yes No Does the patient have a supportive care document (S.C.D) or registered with my care (CMC)? Yes No Does the patient live alone? Preferred place of care : The patient is currently at home , hospital nursing home Date of discharge (if known): Any additional comments/ further information (include any lone worker issues):
Reason for Referral/ Current Assessment of Needs: Relevant Past Medical History and Psychiatric History: Current Medication: Insight Does the patient consent to referral? Has the patient been told diagnosis? Is the carer aware of the patient’s diagnosis? Does the patient discuss the illness freely? Does the patient have a supportive care document (S.C.D) or registered with my care (CMC)? Does the patient live alone? Preferred place of care : The patient is currently at home , hospital nursing home Date of discharge (if known): Yes No Yes No Yes No Yes No Yes No Any additional comments/ further information (include any lone worker issues):
CNWL_Hillingdon_Specialist_Palliative_Care_Team_referral_form.docx