Palliative Care Specialist Nurse Team Step 1 of 4 25% GUIDANCE: Please complete all relevant sections below. REFERRALS WILL NOT BE ACCEPTED IF INFORMATION REQUESTED IS NOT COMPLETED OR IF THE PATIENT REFUSES TO CONSENT. Please state whether this is an Urgent or Routine referral to the Hospice:*Urgent (1-2 working days)Routine (7 working days)See Criteria Here Please state why this referral is urgent*Name of referrer:*Job title:*Base of work:*Date of referral:* Date Format: DD slash MM slash YYYY Contact number:*Email:* Referrer's availability to be contacted:*Has the patient consented to the referral and agreed to share their health records?*YesNoIs the District Nurse involved in the patient's care?*YesNoIf No, please make a referral to the District Nursing Team.Has the patient been known previously to Ashgate Hospicecare?*YesNoPlease state which services the patient has been known to previously at Ashgate Hospicecare*Patient detailsName of patient:*Date of birth:* Date Format: DD slash MM slash YYYY Age:*NHS number:*Telephone:*Mobile:Address:*Is English their first language?*YesNoWhat is their preferred language?*Ethnicity*Caucasian (European)Caucasian (Indian)Caucasian (Middle East)Caucasian (North African, Other)Mixed RaceArctic (Siberian, Eskimo)Indigenous AustralianNative AmericanNorth East Asian (Mongol, Tibetan, Korean Japanese, etc)Pacific (Polynesian, Micronesian, etc)South East Asian (Chinese, Thai, Malay, Filipino, etc)West African, Bushmen, EthiopianOther RaceMarital status*SingleMarriedDivorcedWidowedCo-habitingSeparatedPartnerOtherPlease StateReligion*Advaitin HinduAdventistAetherius SocietyAgnosticAgnosticismAhmadiAmishAnabaptistAncestral WorshipAnglicanAnimistAnthroposophistApostolic PentecostalistArmenian CatholicArmenian OrthodoxArya Samaj HinduAsatruarAshkenazi JewAssemblies of GodAtheistAthiestBahaiBaha'iBaptistBlack MagicBrahma KumariBrethrenBritish IsraeliteBuddhistBulgarian OrthodoxCalvinistCeltic ChristianCeltic Orthodox ChristianChapelChondogyoChristadelphianChristianChristian (non-Catholic, non-specific)Christian ScienceChristian ScientistsChristian SpiritualistChurch of ChristChurch of EnglandChurch of GodChurch of God of ProphecyChurch of IrelandChurch of ScotlandChurch of WalesCongregationalCongregationalistCoptic OrthodoxDeistDruidDruidismDruzeEastern CatholicEastern OrthodoxEckankarElim PentecostalistEpiscopalEthiopian OrthodoxEvangelical ChristianEvangelistExclusive BrethrenFree ChurchFree Church of ScotlandFree Evangelical PresbyterianFree MethodistFree PresbyterianGoddessGreek OrthodoxHaredi JewHarekrisnaHasidic JewHeathenHinduHinduismHumanismHumanistIndependent MethodistIndian OrthodoxInfinite WayJainismJehovah’s WitnessesJehovahs WitnessJewishJudaismKabbalistLatter Day SaintLatter Day SaintsLiberal JewLightworkerLutheranMapucheMasorti JewMennoniteMethodismMethodistMooniesMoravianMormonMuslimNative American ReligionNazareneNazarene ChurchNew AgeNew Apostolic ChurchNew Kadampa Tradition BuddhistNew TestamentNew Testament PentecostalistNichiren BuddhistNonconformistNon-conformistNon-denominationalNonenon-Roman CatholicNot knownNot ReligiousOld CatholicOpen BrethrenOrder of the CrossOrthodox ChristianOrthodox JewPaganPaganismPantheistPentecostalPeyotistPlymouth BrethrenPresbyterianProtestantPure Land BuddhistQuakerRadha SoamiRastafarianReform JewReformed ChristianReformed ProtestantRoman CatholicRoman Catholic ChurchRomanian OrthodoxRoyal ZoroastrianRussian OrthodoxSalvation ArmySalvation Army MemberSanteriScottish EpiscopalianSecularistSerbian OrthodoxSeven-Day AdventistShakti HinduShiloShiva HinduShumeiSikhSikhismSpiritualismSpiritualistSwedenborgianSyrian OrthodoxTaoTaoismUkrainian CatholicUkrainian OrthodoxUniate CatholicUnitarianUnited ReformUnited Reform ChurchUnknownVaishnava Hindu Hare KrishnaVodunWelsh IndependentWesleyanWhite WitchcraftWiccaWiccanYorubaZionistZwinglianDoes the patient live alone?*YesNoPatient's current location:*Key safe number:Please ensure you inform the patient that you have shared this number GUIDANCE: Please complete all relevant sections below. REFERRALS WILL NOT BE ACCEPTED IF INFORMATION REQUESTED IS NOT COMPLETE OR IF THE PATIENT REFUSES TO CONSENT. Next of Kin/Preferred ContactName:*Relationship*Address:*Telephone:*Mobile:Other relevant family memberYes/No*YesNoName:RelationshipAddress:Telephone:Mobile:Patients GPNamed GP:Surgery*Arden House SurgeryAshover Medical CentreAvenue House & Hasland PartnershipBakewell Medical CentreBarlborough Medical PracticeBaslow Health Centre (Ashenfell)Blackwell Medical CentreBlue Dykes SurgeryBrimington SurgeryBuxton Medical PracticeCalow & Brimington PracticeCastle Street Medical CentreChatsworth Road Medical CentreChesterfield Medical PartnershipClay Cross Medical CentreCrags HealthcareCreswell and Langwith Medical CentresDarley Dale Medical CentreDronfield Medical PracticeElmwood Medical CentreEmmett Carr SurgeryEvelyn Medical CentreEyam SurgeryFriendly Family SurgeryGosforth Valley Medical CentreGoyt Valley Medical PracticeHartington SurgeryHasland Medical CentreImperial Road Group SurgeryKillamarsh Medical PracticeLime Grove Medical CentreMoss Valley Medical PracticeNewbold SurgeryNorth Wingfield Medical CentreOak Hill Medical PracticeRoyal Primary CareSett Valley Medical CentreShires Health CentreSt Lawrence Road SurgeryStaffa HealthStewart Medical CentreStubley Medical CentreThe Springs Health CentreThe Surgery @ Wheatbridge SurgeryThe Village SurgeryThornbrook SurgeryTideswell SurgeryWelbeck Drive SurgeryWelbeck Road Health Centre (Bolsover)Whittington Moor SurgeryTelephone:*Is the GP aware of the referral?*YesNoDistrict NurseDistrict Nurse:Telephone:Please refer to the District Nursing Team if you have not already done soOther Professionals InvolvedName of Hospital Consultant:Base:Telephone:Additional professional:Base:Telephone:Palliative Care Consultant / CNS:Social services involved?*YesNoUnknownCare manager:* GUIDANCE: Please complete all relevant sections below. REFERRALS WILL NOT BE ACCEPTED IF INFORMATION REQUESTED IS NOT COMPLETE OR IF THE PATIENT REFUSES TO CONSENT. Diagnosis, Treatment and Past Medical HistoryPrimary(ies) Diagnosis:*Date of Diagnosis*Metastases Diagnosis:Date of DiagnosisPast Medical History*Allergies?*YesNoUnknownPatients allergies:*Please state detailed reason for referral including current symptoms:*Is the patient currently having any treatment / investigations?*YesNoDetails of treatment / investigations:*Does the patient have any mobility, disability, communication / language issues?*YesNoDetails of mobility, disability or communication issues:*Has a DS1500 been completed?*YesNoUnknownAre there any risks we should be made aware of?Are there any hazards in the home?*YesNoNot KnownDetails of hazards in the home:*Are there any pets in the home?*YesNoDetails of pets in the home:*Are there any smokers in the home?*YesNoAny past episodes of aggression / violence?*YesNoPlease provide details*Are there any difficult family circumstances?*YesNoPlease provide details* GUIDANCE: Please complete all relevant sections below. REFERRALS WILL NOT BE ACCEPTED IF INFORMATION REQUESTED IS NOT COMPLETED OR IF THE PATIENT REFUSES TO CONSENT. Documentation to include: List of current medication Latest clinic letter Latest letter from GP GP summary Past medical history DS1500 form PLEASE NOTE THAT YOU MUST INCLUDE A CURRENT LIST OF MEDICATION AND AT LEAST ONE MORE OF THE ABOVE DOCUMENTATION WITH THE REFERRAL TO BE ACCEPTED AND AVOID DELAYPlease upload any supporting documentation you wish to include with the referral: Drop files here or Accepted file types: pdf, docx, doc, xls.