SLT Referral Form | Blackpool Teaching Hospitals NHS Foundation Trust

PATIENT DETAILS:

*Patient Name:

*Date of Birth:

*Home Tel: *Mobile Tel:

*NHS Number:

Address:
*Address1:
Address2:
*Town/City:
*Postcode:

*GP Name:
*Address1:
Address2:
*Town/City:
*Postcode:

Carer Contact details (if appropriate):

*Telephone:

MEDICAL BACKGROUND:

*Relevant diagnosis and past medical history:

*Relevant medication:

TYPE OF REFERRAL:

*I am referring this patient for:

SWALLOWING:

What food and drink is the person NOT managing? Please include the consistencies of the food that the person is NOT managing.

Reason for Referral:

Loss of weight in last 3-6 months?

YesNo

Amount of loss:

New episode coughing/choking on drinks?

YesNo

New episode coughing/choking on food?

YesNo

Has it:

Deterioration of pre-existing swallowing difficulties?

YesNo

Have there been recurrent chest infections?

YesNo

Please state how many and when?

Difficulty swallowing saliva?

YesNo

Other:

How long have symptoms been occurring?

Have there been any relevant investigations, e.g. Videofluoroscopy, Barium Swallow?

Please describe the level of frustration/anxiety that the person/carer is experiencing:

COMMUNICATION:

Is this a new problem?

YesNo

Is the problem getting worse?

YesNo

Please indicate if you have concerns regarding the following:

Understanding spoken language:

YesNo

Speaking and getting the right words out:

YesNo

Reading/writing:

YesNo

Slurred speech:

YesNo

Stammer:

YesNo

Voice Problem:

YesNo

Other:

Please describe the level of frustration/anxiety that the person/carer is experiencing:

Please rate the person's ability to communicate in social or work situations:
0 (No difficulty)12345678910 (Severe difficulty)

Please note: the management of the patient's nutrition, hydration and communication remains the responsibility of the GP or Extensive Care Team until the patient has been seen by the Speech and Language Therapy Service. It is essential that you inform us of any changes to the patient's condition whilst the patient is awaiting assessment.

REFERRER DETAILS:

*Referrer name:

*Referrer profession:

Contact Address:
*Address1:
Address2:
*Town/City:
*Postcode:

*Telephone number:

*Email address:

*Has the person consented to this referral being made?

RISKS:

Are you aware of any potential risks to our staff from the person, their home or other members of the person’s household?

YesNo

If so, please give details: