SLT Referral Form | Blackpool Teaching Hospitals NHS Foundation Trust

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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?	YesNo
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:
Please leave this field empty.