Please answer all questions on both pages



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KHP – Skull Base MDT Proforma



PLEASE ANSWER ALL QUESTIONS ON BOTH PAGES.
When complete please email to kch-tr.skullbase@nhs.net


Patients Name:

Referring Consultant’s Name:

Patients Address:

Referring Hospital:

NHS Number:

DOB




Title:




GP Name and Address




Hospital number




Date of Referral:




CLINICAL QUESTION / REASON FOR REVIEW:



HISTORY OF PRESENTING COMPLAINT: (Date of admission/ clinic)


CLINICAL FINDINGS: (Please include a brief report or email reports with pro-forma)



MANAGMENT (if any):




PAST MEDICAL HISTORY:




CURRENT MEDICATIONS: (Including information on anti-coagulant medication, if stopped when?)



CURRENT WHO PERFORMANCE STATUS –

0

Asymptomatic (Fully active, able to carry on all pre-disease activities without restriction)



1

Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work)



2

Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours)



3

Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours)



4

Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)



5

Death



INVESTIGATION RESULTS

CT Head

Yes No

Dates:      

MRI Head

Yes No Scan Location:      

Dates:     

Other imaging:

Yes No

Dates:      

Audiometry

Yes No (Please attach)

Dates:      

Histology

Yes No

Dates:      

Print Name:

Date:




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