This form is partially unlocked (indicated by the Ð symbol) to allow referrer to delete sensitive/extraneous data)
Date of referral letter	Short date letter merged 	Date of referral if different to stated:  	     	

Name:	Full Name 	DOB:	Date of Birth 	NHS No	NHS Number 	

Attach this form to the e-referral 
(see ‘suspected Inflammatory Arthritis – URGENT’)
If e-RS not available, then send this ‘service form’ AND ‘Referral Header Sheet’ by secure email 
NB: Emailed referrals must be sent from a secure email address e.g. nhs.net

This form will serve as the referral letter. Thank you for carefully considering the need to refer to this service, intended for people with new onset inflammatory arthritis.

Please note that due to pressures on appointments in this service, referrals will be triaged by a Consultant Rheumatologist. 

This is a RAPID ACCESS CLINIC, and we will aim to see patients within 15 days or referral. 
Patients will have TWO appointments at the Freeman hospital, one week apart. 
•	At the first of these, they will undergo musculoskeletal ultrasound and blood tests and X rays as appropriate; they may also be offered the opportunity to participate in research.
•	At the second, they will be reviewed by their Consultant Rheumatologist to discuss their results and A detailed management plan.

Please complete all fields of the referral.  
Please include requested blood tests results where they are available.  
However, because blood tests will normally be undertaken as part of the assessment in secondary care, please do not delay referrals by requesting investigations if an inflammatory arthritis is suspected clinically. 

X rays do not need to be performed.  

Please do not prescribe corticosteroid.  If you feel this is necessary, please contact the on-call registrar for urgent review.

If you have concerns about SEPTIC ARTHRITIS or a patient with LARGE JOINT inflammatory arthritis, please contact the team directly by asking to speak to the on-call rheumatology registrar or consultant.   0191 2336161

Ð Reason for Referral 
Note to referrer:  Extraneous/sensitive information MUST BE DELETED from the consultation below
Consultations 

Any Other information not included in ‘reason for referral’ above
     

Has the patient been reviewed by rheumatology before?	 Yes	 No	
If yes, and not at Freeman Hospital, please include details below and/or attach relevant correspondence	
Details 	Further information attached?     Yes	

     

Blood test results, if known  (there were a lot more bloods mentioned in current form?
Blood test	Latest Result 	Requested	
CRP	Single Code Entry: Serum CRP (C reactive protein) level  	Single Code Entry: Serum CRP (C reactive protein) level  		
ESR	Single Code Entry: Erythrocyte sedimentation rate  	Single Code Entry: Erythrocyte sedimentation rate  		

Weight	Single Code Entry: Body weight    	
Height	Single Code Entry: Standing height  	
BMI	Single Code Entry: Body mass index  	

Clinical features suggestive of early inflammatory arthritis in this patient include: Please ‘x’ all that apply
1 and 2 must be present, 
1		Persistent symptoms < 12 months	
2		Involvement of the small joints (hands, wrists, ankle and/or feet)	

Plus one of 3 – 6.
3		Tenderness and/or swelling of > 2 joints (not including DIP, 1st CMC or 1st MTP Joints)	
4		Early morning stiffness > 30 minutes	
5		Systemic symptoms and/or history of inflammatory bowel disease uveitis or psoriasis	
6		Positive MCP/MTP squeeze test	

PLEASE COMPLETE THE REST OF THIS FORM

Referrer details
Name of referrer:	Referring User      	  Date of referral:	Short date letter merged 	
Referring Organisation
Organisation Name , Organisation Full Address (single line)   
Tel:  Organisation Telephone Number 
Email: Organisation E-mail Address 
Fax:  Organisation Fax Number  	GP details
Usual GP Full Name             
Usual GP Organisation Name   Usual GP Full Address (single line)  
Tel:  Usual GP Phone Number  
Fax:  Usual GP Fax Number       	
Name of GP to address correspondence to, if different to accountable GP	     	

Patient details
Name:	Full Name  	Address:	Home Full Address (stacked)  	
Gender:	Gender(full)  			
DOB & Age:	Date of Birth Age: Age  			
NHS number:	NHS Number  			
Patient Contacts:	Home: 	Patient Home Telephone  	Mobile:	Patient Mobile Telephone  	
	Work: 	Patient Work Telephone  	Email: 	Patient E-mail Address  	
	Carer/Advocate:  The patient has confirmed the following person should be included in correspondence – Name:          Contact Details:        	
Contact Consent:	  Can leave message on answer machine 
  Can contact by text    
  Can contact by Email	NB:  Not all services use Texts or Emails as a method of communication.	
Ethnicity: 	Ethnic Origin  	
Interpreter: 	  Yes         Language: Single Code Entry: Main spoken language English...         	
Accessibility Needs:	 Wheelchair access         
 Deaf  Single Code Entry: Partial deafness...          
 Registered Blind Single Code Entry: Registered blind  
  Learning Disability,  Single Code Entry: On learning disability register  Single Code Entry: Moderate learning disability...  
  Other disability needing consideration       
  Accompanied by Carer	
Risks:	Vulnerable Adult  (Details of any recording within last 3 yrs)  Single Code Entry: Vulnerable adult  Single Code Entry: No longer a vulnerable adult...  
Single Code Entry: Difficult intubation  
    Other:         	
Other: Single Code Entry: Military veteran  Single Code Entry: Left military service  Single Code Entry: History relating to military service  Single Code Entry: History relating to Army service...  
Single Code Entry: Has a carer  Single Code Entry: Is no longer a carer  Single Code Entry: Is a carer    	

Accessible information
Communication support: Uses a legal advocate... 
Contact method: Requires contact by telephone... 
Information format: Requires information verbally...
Professional required: Interpreter needed - British Sign Language...
If you have any problem with this form or suggested changes, please control & click here to open direct email.  (NB: NOT TO BE USED FOR REFERRING A PATIENT) Suspected Early Inflammatory Arthritis Referral Form January 2021 V1 EMIS Web SNOMED Gateshead