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Children's hearing referral form for parents-guardians

Description
Parent/Guardian referral Community Paediatric Audiology Referral for children with hearing concerns Please complete all sections Please sen
Url
/Media/UHS-website-2019/Docs/Services/Child-health/Childrens-hearing/Childrens-hearing-referral-form-for-parents-guardians.docx

Children's hearing referral form for health professionals

Description
Community Paediatric Audiology Referral for children with hearing concerns Please send this referral form to: Email: paedaudiologyreferrals
Url
/Media/UHS-website-2019/Docs/Services/Child-health/Childrens-hearing/Childrens-hearing-referral-form-for-health-professionals.docx

Appendix I - UHS HNIG presciption form

Description
HNIG
Url
/Media/UHS-website-2019/Docs/Post-Exposure-Prophylaxis-Policy/AppendixI-UHSHNIGPresciptionForm.pdf

General genetics family history questionnaire

Description
Date ......................................... FAMILY HISTORY QUESTIONNAIRE Wessex Clinical Genetics Service Princess Anne Hospital Coxford Road Southampton SO16 5YA Tel: 023 8120 6170 GeneticsTeam@uhs.nhs.uk www.uhs.nhs.uk/departments/genetics You have been referred to the Wessex Clinical Genetics Service. It would be helpful to gather some more information about the family before the appointment. All information you give will be kept as part of your NHS record and will be kept confidential. Please return this questionnaire as soon as possible for us to process all the information. If you have any queries or difficulties in completing the form please do not hesitate to contact us. If you are unable to complete all the sections, please still return the form. Your Details (Person Referred): Title: _______ Forename(s): _____________________ Surname: ______________________ Previous surname(s): __________________________ Name you prefer to be addressed by (optional): _______________ Pronouns (optional): __________ Address: __________________________________________________________________________ Telephone number: ____________________ Email Address: __________________________ If you are completing this form on behalf of the person referred, please fill in below. Name: _______________________________________ Relationship to patient: _____________________________ Address: __________________________________________________________________________ Telephone number: ____________________ Email Address: __________________________ We may contact you by telephone if we need further details. We will not disclose where we are calling from to anyone apart from yourself, without your permission. Are you happy for us to contact you by telephone? YES/NO If you have an answer-phone, are you happy for us to leave a message? YES/NO Can we disclose where we are calling from should anyone apart from you answer the phone? YES/NO Would you prefer to receive a letter, asking to call the department, should we need further details? YES/NO If the person referred is a Looked After Child, please provide the contact details for the social worker: __________________ Telephone No: _______________________________ Address: ____________________________________________________________________________________ Email: _______________________________________ Your immediate family - We would like to know details of family members, both with and without any health or learning problems. Please note any additional information, such as donor conception, adoption, or anything else you would like us to understand about this part of your family: ___________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________ Relative (of person referred) Please give details of any health, developmental or learning problems (including any relevant genetic test results) Hospital where treated Person Referred Sisters of person referred full or half (if half, please state through mother or father) Brothers of person referred full or half (if half, please state through mother or father) Mother of person referred Father of person referred Additional Family History Please include below anyone else in the family that has any similar health, developmental or learning problems related to the referral reason Please note any additional information, such as donor conception, adoption, or anything else you would like us to understand about your family: ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Other Relatives (please include how they are related to you i.e. son) Please give details of any health, developmental or learning problems (including any relevant genetic test results) Hospital where treated If you know of anyone else in your family who has been seen by another Genetics Service or referred to Wessex Clinical Genetics Service, it would be helpful to provide some details here: Genetics Service where seen: ____________________________________________________________ We may get in touch asking you to pass on a consent form to your relative to access their genetic report. Are you in contact with the above relative? YES/NO If you already have a copy of this genetic result, it would be helpful to return this form with a copy attached. About you Some conditions are more common in certain ethnic groups. What is your ethnicity? _______________________ Are you or your partner currently pregnant? YES/NO If yes, what is the due date? ____________________ Are you and your partner biologically related? YES/NO Have you been diagnosed with any major illness or undergone any surgery in the past? Please give details including dates, names of hospital and specialists seen. Please also list any current medications. Is there any other information about you or your family members that you feel may be relevant? What are your main questions you would like to be addressed by the genetics service? Thank you for completing this questionnaire For official use only Date Issued: Patient Number: G Number: Date Returned:
Url
/Media/UHS-website-2019/Docs/Services/Genetics/General-genetics/General-genetics-family-history-questionnaire.pdf

Appendix H - UHS RIG and rabies vaccine prescription form

Description
RIG,rabies
Url
/Media/UHS-website-2019/Docs/Post-Exposure-Prophylaxis-Policy/AppendixH-UHSRIGandRabiesVaccinePrescriptionForm.pdf

Cancer family history questionnaire

Description
Date ......................................... CANCER FAMILY HISTORY QUESTIONNAIRE Wessex Clinical Genetics Service Pr
Url
/Media/UHS-website-2019/Docs/Services/Genetics/Cancer-genetics/Cancer-family-history-questionnaire.pdf

WGLS (combined) user handbook

Description
University Hospital Southampton NHS Foundation Trust DOC987 Revision 1/ WRGL 33687 V1.0 Wessex Genomics Laboratory Service Wessex Genomics Laboratory
Url
/Media/UHS-website-2019/Docs/Services/Pathology/WGLS-combined-user-handbook.pdf

Appendix B - VZIG risk assessment and prescription form

Description
Varicella zoster Immunoglobulin for post-exposure prophylaxis (PEP)Please note that UHS Pharmacy will issue VZIG only when both RISK ASSESSMENT and PRESCRIPTION FORM ar
Url
/Media/UHS-website-2019/Docs/Post-Exposure-Prophylaxis-Policy/AppendixB-VZIGRiskAssessmentandPrescriptionForm.pdf

Laboratory medicine user handbook rev 22

Description
University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 G3.7 Laboratory Medicine Labora
Url
/Media/UHS-website-2019/Docs/Services/Pathology/Lab-med/Laboratory-medicine-user-handbook.pdf

Expressing breast milk for your baby - patient information

Description
A guide to expressing breast milk for your baby.
Url
/Media/UHS-website-2019/Patientinformation/Neonatal/Expressing-breast-milk-for-your-baby-3251-PIL.pdf
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