Refer a Patient Page (2/2) Does the patient have or have they suffered from: Please enable JavaScript in your browser to complete this form.Any respiratory illness, such as asthma, COPD or bronchitis?YesNoAny cardiovascular disease, such as angina, high/low blood pressure, heart valve disease or endocarditis? YesNoAny endocrinological disease, such as diabetes, hypo/hyperthyrodism, Cushing's or Addison's disease? YesNoAny urological condition, such as kidney disease or urinary tract conditions?YesNoAny gastrointestinal disease, such as liver disease, ulcerative colitis or GORD?YesNoAny psychiatric illness, such as severe anxiety/depression, schizophrenia, dementia or Alzheimer's disease? YesNoAny bone or joint disease, such as osteoarthritis, rheumatoid arthritis or osteoporosis? YesNoAny blood-borne disease, such a Hepatitis B or HIV?YesNoAny episodes of persistent bleeding or bruising after injury, such as after a tooth extraction or surgery?YesNoA learning disability?YesNoA substance misuse disorder?YesNoAny illness or operation that required them to be in hospital?YesNoDoes the patient have any disabilities such as a visual or hearing impairment, or reduced mobility?YesNoAny other conditions or disabilities not listed above?YesNoDoes the patient use any nicotine/tobacco products?YesNo How smoked If yes, what does the patient use?CigarettesSmokeless tobaccoVapeBetel/Areca nut (Paan/Guar)For cigarettes: How many years has the patient smoked for? Selected Value: 0 How many units of alcohol per week, if any? Selected Value: 0 If you answered 'Yes' to any of the above, please provide details: Please list any regular medications the patient takes: Please list any allergies the patient has:What is the patient's BMI?Submit Referral Request
