COPD and Heart Failure Referral Form

Heart Failure Support Programme Criteria

Patients’ main clinical problem is HFREF, HFPEF, or AF.
Patient has been assigned a NYHA score 2-3
Patient has uncontrolled physical symptoms despite optimal dosage of evidence-based respiratory medication
Two acute hospital admissions in the last 12 months
Patients have complex psychosocial and spiritual needs.

Patients’ main clinical problem is COPD.
Patients have been assigned a MRC Breathlessness score of 2-3
Patient has uncontrolled physical symptoms despite optimal dosage of evidence based respiratory medication
Two acute hospital admissions in the last 12 months
Patients have complex psychosocial and spiritual needs.

NHS No:

Name:

Date of Birth:

Address:

Postcode:

Telephone No:

Next of Kin:

NOK Address:

NOK Tel. No:

General Practitioner:

Surgery & Tel. No:

Hospital Consultant:

Surgery & Tel. No:

Hospital Consultant:

Community Nurse Involvement

If Yes Who?:

Transport Required

On Heart Failure Register

SR1

NYHA Score

MRC Score

Date of initial diagnosis and reason for referral:

How many acute hospital admissions in the last 12 months (as per referral criteria):

Medical history:

Medication (please include patient summary sheet):

Limiting Symptoms:

Known Allergies:

Referral Date:

Referring Nurse / Doctor:

Contact Details:

Please tick any of the following long-standing conditions that are applicable?

Hold control for multiple

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