ALL BOXES MUST BE COMPLETED THEN EMAIL TO:

Debbie.field1@nhs.net

Referral Proforma: Long term respiratory care SLEEP AND VENTILATION TEAM RBHT (for Non-invasive assessment, Invasive ventilation support/weaning/ Tracheostomy support)
Referral details
Referrers name:	Date of referral:
Name of referring hospital / GP / service:	Ward (if hospital):
Name of responsible consultant/HCP:	Contact number:
Reason for referral:	Patients location:
Patient demographics
Patient Name:	NHS number:
Sex: Male / Female	D.O.B:
Home address: Contact number:
GP name: Surgery address: Phone number:
Carers/NOK Name: Relationship Contact number:
Clinical details
COVID-19 SWAB DATE RESULT Primary Diagnosis (including recent events/HPC):
Past Medical History:
Resuscitation status / Ceiling of Care:
Current Condition/treatment to date:
Current NIV compliance (e.g hrs used each night)	Able to put own mask on and off?	Requires package of care at home due to NIV?
Relevant investigations (CT/CXR/ECG/Sleep study/Spirometry):
Latest ABG result: Date Time FiO2 On/off NIV Ph PaCO2 PaO2 HCO3 BE SaO2 If NIV - Current non-invasive ventilation settings: Mode IPAP / PS EPAP BPM Ti Rise FiO2 Target Tv (if iVAPS/AVAPS) Hrs used last 24 Hrs If TIV - Current invasive ventilation settings: Mode PS PEEP BPM FiO2 Avg RR Avg VTE Tracheostomy tube make/model: Date of insertion: Cuff up/down: