Living Well With Multiple Symptoms Pilot Referral Form

This form contains merged data from the medical record which appears in red font or under red headings. Please delete any information which is irrelevant to the referral.	

About this Form	
This form should be used to refer patients, aged 18 years or older, to the Bromley Healthcare Post-COVID Syndrome Assessment Clinic AND/OR the multiple symptom Pilot .
1. Suspected or Confirmed Post-COVID Syndrome
Access to this clinic is for patients with suspected or confirmed Post-COVID syndrome, sometimes known as ‘Long COVID’.  The syndrome usually presents as clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any body system.
NICE defines these patients as people with signs and symptoms that develop during or following an infection consistent with COVID-19 which:
•	are not explained by an alternative diagnosis
•	continue for more than 12 weeks
o	If referring after 12 weeks, complete this form & make a standard outpatient referral on eRS
o	If considering referral before 12 weeks, investigate as per local and NICE guidance, refer to hospital for advice and guidance
Patients may be referred based on clinical diagnosis alone in the absence of a previous positive SARS-Cov-2 test.
2. Multiple Symptoms Pilot
People with persistent symptoms which may be diagnosed as Post Covid or triggered by another acute illness or intervention and those who find it difficult to manage their symptoms as part of their long term condition are also eligible to access this service as part of a pilot programme. 

If you see anyone who meets the following criteria please make a referral to the this service.  
Adult aged 18+
✅ 3 or more persistent symptoms (lasting >12 weeks), including at least one major symptom:
Major Symptoms:
•	Breathlessness
•	Brain fog
•	Fatigue
	
Other symptoms including but not limited to such as
 
•	palpitations
•	body pain
•	headache 
•	dizziness
•	low mood
•	anxiety symptoms
•	cough
•	sleep problems 
•	neurological symptoms	

✅ Symptoms significantly affecting daily living or quality of life
✅ Underlying conditions have been medically optimised
✅ Face-to-face clinical assessment completed
✅ Appropriate investigations performed
Please ensure that all patients have undergone the required face-to-face clinical assessment and investigations have been performed, before referring to the service. 
Once completed, this form should be emailed using NHSMail to: bromh.communitypostcovid@nhs.net
Service Provider Details: Bromley Healthcare CIC Ltd, Central Court, 1 Knoll Rise, Orpington BR6 0JA  .☎ 0300 330 5777	
1. Patient Details 	
Title: 	First Name: 	Surname: 	
NHS Number: 	Date of Birth: 	Gender: 	Age: 	
Address: 	
Telephone:        (Home)          (Mobile) 	
Email: 	
Ethnicity:  	
2. Referral Details 	
Date of Referral
	Form Completed By: 
Referring GP (If form completed on GP's behalf):       	
Surgery: 	
Address: 	Telephone: 	
Email: 	

3. Carer Details - Please complete if a carer should be the main point of contact	
  	
Title:      	First Name:      	 	Surname:      	
Address (if different to patient):      	
Telephone: 	(Home)      	(Mobile)      			Email:      	
Relationship to Patient:      	Is the carer aware of the referral?     Yes 	 No	

4.  Reason for Referral	
Outline, in one or two sentences only, the summary reason/s for referral, indicating the most troublesome types of symptoms e.g. respiratory. You should provide a more detailed history at Section 6.
	
5.  Severity of Acute Episode, if applicable	
Indicate the severity of the acute illness.

Please provide details of the impact of the patient’s symptoms on their activities of daily living or ability to work, e.g. if there is a risk of loss of employment etc. This information will assist in the triage team assessing the urgency of the referral.
	
6.  History of Presenting Complaint / Relevant Consultation Notes	
Provide a detailed history of the presenting complaint.
     
Consultations

7.  Examination	
Pulse – Resting (mandatory)	
MANDATORY REQUIREMENT, please code in the patient record.     	

BP – Sitting (mandatory)	
MANDATORY REQUIREMENT, please code in the patient record 	

Standing BP (Optional - for patients with fatigue/dizziness)	
      	

Oxygen Saturation – resting (mandatory)	
MANDATORY REQUIREMENT, please code in the patient record.      	

Oxygen Saturation – exertional (Optional - after 1 minute sit to stand or 40 step test)	
     	

Mandatory fields are highlighted in amber.  Please ensure that all of these contain merged data or are completed manually. 

GAD7: 
PHQ9: 	
8.  Required Blood Tests	
This section contains merged mandatory blood test results which should be no more than 4 weeks old.  Please review the list below and ensure that any missing tests are performed whilst the patient awaits an appointment. 

	

	

	

	

	

	

	

	

	
9. Mandatory Chest X-Ray 	
This section merges the latest chest x-ray report. Chest x-ray in the last 4 weeks is a mandatory requirement for referral.  If the patient has undergone a chest x-ray which was not requested by the GP and/or has not merged below please ensure that you obtain a copy of the report and attach it to this referral. 
MANDATORY- You must request and review a CXR before referral  	

10. Further Information 
Please type/paste/merge further information below	
     

Merged Data - Any merged information which is irrelevant to the referral should be removed.

COVID Specific Data

					

 

Problems
Active

				

Significant Past

				

 

Medication
Acute
Drug	Dosage	Quantity	Last Issued On	

Repeat

 
Allergies

			

Recently Recorded Optional Investigations	

Caution: Recipient please note that the information provided is limited to data recorded on the GP patient record and may not include the results of tests performed by other care providers or data which has not been coded.	

Post-COVID Syndrome Community Assessment Clinic (Bromley) Referral Form 1-01 230521
Document created by the Referrals Optimisation Team, One Bromley. Feedback or enquiries about this form should be directed to: broccg.emisrp@nhs.net. For service related enquiries, please contact the service provider (details in About this Form section).