ASTHMA TEAM REFERRAL
FORM
CHILDREN’S HOSPITAL AT HOME ASTHMA TEAM
Tel: 020 8274 6422
Email: [email protected]
Fax: 020 8274 6420
CHILD’S DETAILS
Child’s Full Name……………………………………………………………………D.O.B……………………….
MALE / FEMALE
NHS NO:………………………………….. MRN/M000 NO:………………………………
Address ………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………..
Post Code …………………. Home Tel No. ……………………………………………………………………
Mobile No(s)..……………………………………………………………………………………………………..
Parent / Guardian’s Name ( include surname if different from child)…………………………………………
Language spoken ………………………………. Interpreter required?
Yes / no
Please give details of any communication difficulties:………………………………………………………….
GP- PATIENT MUST HAVE CROYDON GP
GP Name and Address……………………………………………………………………………………………
……………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….
Tel No. ……………….……………………… Fax No. …………….………………………………………….
OTHER PROFESSIONALS
Name of School/Nursery ……………………………………….………….…… Tel no. ………………………..
Name of Health Visitor (if applicable) ………………………………………
Tel no ….……………………..
Name of Social Worker (if applicable) ……………………………………… Tel no. ……………………….
Child Protection Plan (please circle)
Yes
No
REASON FOR REFERRAL
Recent hospital admission
□
Instruction on inhaler technique

Asthma support and education

MEDICATION
Salbutamol 100 mcg

Beclometasone 50mcg BD/100mcg BD /200mcg BD

CROYDON HEALTH SERVICES
D:\81923695.doc Last Reviewed: 16/04/2015
Other medication …………………………………………………………………………………………
Allergies …………………………………………………………………………………………………………
REFERRER DETAILS
Name…………………………………………………… Role…………………………………………..
Contact number……………………………………. Email………………………………………………….
PLEASE ENSURE PARENTS/GUARDIANS ARE AWARE OF REFERRAL
Referrer Signature……………………………………
Yes / No
Date…………………………………………………..
THIS REFERRAL IS FOR A SINGLE INTERVENTION ONLY AND NOT CASELOAD MANAGEMENT
WE WILL CONFIRM RECEIPT OF THIS FORM
Any other information that should be made known to the Asthma Team, that could have implications for
safety or their approach to the client/family
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
FOR OFFICE USE ONLY
Date Received …………………………………………………..
Referrer contacted and receipt of referral confirmed:
Date …………………. Initials……………………………
CROYDON HEALTH SERVICES
D:\81923695.doc Last Reviewed: 16/04/2015