ࡱ>  Objbj ËËH(  xx$$$8\T$4D:::R,,,q4s4s4s4s4s4s4$6N94,,^l,",,4xx:R42/2/2/,|xl:Rq42/,q42/2/1,2:ad -R1]44041,":\-":22"":52(,,2/,,,,,44&. ,,,4,,,,":,,,,,,,,, >:  Patient Self-Referral to Podiatry Services This form should only be used for patients (over the age of 18) wishing to have Podiatry for foot related problems Please note: your referral will be rejected if it does not meet the Podiatry Service Criteria for treatment; if this is the case, you will be informed by post. Appointment queries: Tel: 020 3316 1111 / 0203 316 1600 (10- 4pm) or email:  HYPERLINK "mailto:arti.centralbookings@nhs.net / haringey.adult-referrals@nhs.net" arti.centralbookings@nhs.net / haringey.adult-referrals@nhs.net  *Email address and mobile number supplied will not be used for any other purposes or shared with any other parties Please complete ALL sections of the form, incomplete forms will be returned which will cause a delay in the management of your problem. NO appointments can be booked until a FULLY COMPLETED form has been received. Once completed this form can be: Emailed:  HYPERLINK "mailto:arti.centralbooking@nhs.net" arti.centralbooking@nhs.net OR  HYPERLINK "mailto:haringey.adult-referrals@nhs.net" haringey.adult-referrals@nhs.net Posted: The Central Referral Management Team Level 4, Highgate Wing, Dartmouth Park Hill N19 5JG Handed In To: Lordship Lane Health Centre, 239 Lordship Lane, London, N17 6AA Hornsey Central Neighbourhood Health Centre, 151 Park Road, London, N8 8JD Holloway Community Health Centre, 11 Hornsey Street, London N7 8GG Finsbury Health Centre, 17 Pine Street, London EC1R 0LP Surname: First name: Male  FORMCHECKBOX Female  FORMCHECKBOX Date of Birth:Address: Post code:Daytime Tel No: NHS No: Hospital No:Is an interpreter required? Yes  FORMCHECKBOX  No  FORMCHECKBOX If Yes, what language:Optional for data monitoring purposes only. How would you describe your ethnic origin? Next of kin: Telephone No : Contact Address:GPS DETAILSName:Have you consulted your GP about this problem? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If Yes, what did they recommend: Practice: Tel No:Give a brief description of your problem including how it started. (please only refer for one condition)Area of pain / How it started / Any previous treatments? How long have you had this problem?Less than 2 weeks  FORMCHECKBOX 2 6 weeks  FORMCHECKBOX More than 6 weeks  FORMCHECKBOX More than 1 year  FORMCHECKBOX Is your problem:Getting betterGetting worseStaying the sameHave you had any investigations for this problem? (E.g. Scans, X-rays, Blood tests)Yes  FORMCHECKBOX No  FORMCHECKBOX If Yes, please give details:  Name: Date of Birth:General Health - Please tick if you have any of the following:Lung problems FORMCHECKBOX SINCE THE ONSET OF THIS PROBLEM Do any of the following apply to you? If you have the symptoms please tickHeart Problems FORMCHECKBOX Epilepsy FORMCHECKBOX Osteoarthritis FORMCHECKBOX Areas of the foot which are red/ /swollen/hot/inflammation  FORMCHECKBOX Rheumatoid Arthritis FORMCHECKBOX Open wounds on the foot (especially if you are diabetic) FORMCHECKBOX Osteoporosis FORMCHECKBOX Foot ulcer FORMCHECKBOX Diabetes FORMCHECKBOX Feet which are cold/dusky/painful  FORMCHECKBOX Surgery / Operations FORMCHECKBOX Night cramps or cramps when walking a short distance in legs FORMCHECKBOX Previous Fractures FORMCHECKBOX If you have ticked any of these symptoms, and you HAVE NOT seen a doctor for this symptom, it is essential you arrange an URGENT appointment with your GP or attend your local A&E Department DO NOT SEND IN THIS FORM UNTIL YOU HAVE SOUGHT FURTHER ADVICECurrent or Past Pregnancy FORMCHECKBOX Any Major Illness FORMCHECKBOX If Yes to any, please give details: Please list any Medicine you are taking (leave blank if not on medication): Employment status:Employed  FORMCHECKBOX Unemployed  FORMCHECKBOX Retired  FORMCHECKBOX Student  FORMCHECKBOX Carer  FORMCHECKBOX Please give details: Any activities you do (E.g. Sports, Gym, Hobbies). Please give details: Due to your current problem you are unable to:Work  FORMCHECKBOX Participate in activity/sport  FORMCHECKBOX Care for dependent  FORMCHECKBOX Other  FORMCHECKBOX Please give details: Please note: We do not treat verrucas and we do not see patients for basic nail cutting unless they have a medical need (such as diabetes) which put their feet at risk of complications, and are unable to manage their own foot care needs.     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