Patient Details

Patient Name	Title Given Name Surname	
Patient Gender	Gender	
Date of Birth	Date of Birth	
NHS Number	NHS Number	

Patient Address	Home Full Address (stacked)	
Home Telephone	Patient Home Telephone	
Mobile Telephone	Patient Mobile Telephone	
Work Telephone	Patient Work Telephone 	

Next of kin         

GP Details

Referring GP	Current User	
Usual GP	Usual GP Full Name	
Registered GP	Registered GP Full Name	
Practice Name	Organisation Name 	
Practice Address	Organisation Full Address (single line) 	
Practice Telephone	Organisation Telephone Number 	
Practice Code		Organisation National Practice Code	

Date of referral 	Short date letter merged 

Return this form to the York Hospital

Send to:

Respiratory Team, York Hospital, Wigginton Road, York, YO31 8HE

By fax: 01904 726895

Respiratory Team Telephone Number: 01904 726448

Service Relevant Details		
	
Patient Name	Title Initial Last Name
Date of Birth	Date of Birth
NHS Number	NHS Number	
	
Confirmed diagnosis/ reason for referral  Other      

Smoking history: 	Single Code Entry: Tobacco consumption
Pack Years:  	Single Code Entry: Pack years	

SpO2 score Single Code Entry: Blood gases

SpO2 persistently ≤ 92% in stable state 

Acceptance/Exclusion Criteria
              Acceptance
•	Adult patients with oxygen saturations <92% breathing air
•	Treatment for End of Life Care if the patient is hypoxaemic
•	Completed referral form
Exclusions
•	Patients under 18 years
•	A non-hypoxaemic breathless patient
•	SpO2 >92%
•	Patients that smoke
•	The above may not be an exhaustive list and consideration will be given in individual circumstances

Generic Patient Clinical Details

Patient Name	Title Initial Last Name	
Date of Birth	Date of Birth	
NHS Number	NHS Number	

Problems
Medication
Allergies

Most recent blood pressure
Specific Codes Table: O/E - blood pressure reading

Other relevant history (start typing in grey box which will expand as needed)
     

For Office Use	
Venue of 1st assessment and date	
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