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Refer a patient

Speech and language therapy - Adult

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Are you requesting assessment of: * required



Part 1
Patient details
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(By giving us your mobile number you consent to receiving SMS reminders of appointments. If you wish to opt out at any time please contact us.)
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(please provides dates of diagnosis/onset of illness if known)
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To what degree does the patient exhibit the following:
Recent deterioration in general health: * required




Difficulty maintaining seated posture: * required




Pain: * required




Fatigue: * required




Drowsiness: * required




Distractability/reduced concentration * required




Challenging behaviours: * required





(e.g.: two person visits, which direction to approach the patient, etc.)
Mental capacity and consent to referral
Does patient have capacity to consent to referral to SLT? * required


Patient aware of, and agrees to, referral to SLT: * required


If NO to above is referral being made in patient’s best interests?: * required


Any previous capacity assessments or best interests decisions?: * required


Referrer
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Part 2
Swallowing difficulty

Please indicate to what degree that patient exhibits the following:

Difficulty maintaining oral hygiene:




Respiratory difficulties, including chest infections:




Difficulty eating/drinking independently/unaided:




Unintentional/unexplained weight loss:




Distress as a result of swallowing difficulty:




Please indicate what type of food the patient is having at the moment:






Please indicate what type of drink the patient is having at the moment:







Is this swallowing difficulty:


Is this swallowing difficulty:




Part 3
Communication difficulty

Please indicate to what degree the patient exhibits the following:

Difficulty understanding spoken language:




Difficulty using spoken language:




Difficulty understanding written language:




Difficulty using written language:




Slurred speech:




Voice changes (e.g.: husky, croaky, strained):




Stammering/non-fluent speech:




Quiet voice/reduced volume:




Distress as a result of communication difficulty:





Is this communication difficulty:


Is this communication difficulty:




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