Are you a Dorset GP?
* Required
Yes
No
If yes, please use the MAS referral form on SystmOne.
Are you are a registered professional working outside of NHS Dorset Health Services?
* Required
Yes
No
Are you a registered professional working in an NHS Dorset Health Trust (i.e. UHD, DHC)
* Required
Yes
No
Have you discussed this with the GP?
* Required
Yes
No
Have you discussed this with the patient?
* Required
Yes
No
Have you have ruled out other physical or mental health causes of cognitive changes?
* Required
Yes
No
Are you able to provide blood results within the last six months?
* Required
Yes
No
Have you contacted MAS on 0300 303 5342 about this referral?
* Required
Yes
No
Have you been advised to use this form by MAS?
* Required
Yes
No
Date of referral
* Required
Referrer's name
* Required
Email
* Required
Team/organisation
* Required
Contact number
* Required
Patient details
Name
* Required
NHS number
* Required
Address
* Required
Date of birth
* Required
Preferred contact number
* Required
Gender
* RequiredFemale Male Not specified Unknown
Sexual orientation
Heterosexual/straight Gay/lesbian Bisexual Other Unknown Prefer not to say
Marital status
Single Married Divorced/person whose civil partnership has been dissolved Civil partnership Not disclosed Not known Separated Widow/surviving civil partner
Ex-Armed Forces?
* Required
Yes
No
Accommodation status
MA00 Mainstream Housing MA01 Owner occupier MA02 Settled mainstream housing with family/friends MA03 Shared ownership scheme e.g. Social Homebuy Scheme (tenant purchase percentage of home value from landlord) MA04 Tenant - Local Authority/Arms Length Management Organisation/Registered Landlord MA05 Tenant - Housing Association MA06 Tenant - private landlord MA09 Other mainstream housing (not listed) HM00 Homeless HM01 Rough sleeper HM02 Squatting HM03 Night shelter/emergency hostel/Direct access hostel (temporary accommodation accepting self referrals, no waiting list and relatively frequent vacancies) HM04 Sofa surfing (sleeps on different friends floor each night) HM05 Placed in temporary accommodation by Local Authority (including Homelessness resettlement service) e.g. Bed and Breakfast accommodation HM06 Staying with friends/family as a short-term guest HM07 Other homeless (not listed) MH00 Accommodation with mental health care support MH01 Supported accommodation (accommodation supported by staff or resident caretaker) MH02 Supported lodgings (lodgings supported by staff or resident caretaker) MH03 Supported group home (supported by staff or resident caretaker) MH04 Mental Health Registered Care Home MH09 Other accommodation with mental health care and support (not listed) HS00 Acute/long stay healthcare residential facility/hospital HS01 NHS acute psychiatric WARD HS02 Independent hospital/clinic HS03 Specialist rehabilitation/recovery HS04 Secure psychiatric unit HS05 Other NHS facilities/hospital HS09 Other acute/long stay healthcare residential facility/hospital (not listed) CH00 Accommodation with other (not specialist mental health) care support CH02 Refuge CH03 Non-Mental Health Registered Care Home CH09 Other accommodation with care and support (not specialist mental health) (not listed) CJ00 Accommodation with criminal justice support CJ12 Other accommodation with criminal justice support (not listed) SH00 Sheltered Housing (accommodation with a scheme manager or warden living on the premises or nearby, contactable by an alarm system if necessary) SH01 Sheltered housing for older persons
Ethnicity
* Required Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Any other Asian background Black, African, Caribbean or Black British - African Black, African, Caribbean or Black British - Caribbean Black, African, Caribbean or Black British - Any other Black, African or Caribbean background Mixed or Multiple ethnic groups - White and Black Caribbean Mixed or Multiple ethnic groups - White and Black Caribbean Mixed or Multiple ethnic groups - White and Black African Mixed or Multiple ethnic groups - White and Asian Mixed or Multiple ethnic groups - Any other Mixed or Multiple ethnic background White - English, Welsh, Scottish, Northern Irish or British White - Irish White - Gypsy or Irish Traveller White - Any other White background Any other ethnic group
Employment
Next of kin name and contact details
GP details
Registered GP
* Required
Practice address
* Required
Telephone
* Required
Referral details
Is this a:
* Required
New referral for assessment
Referral for someone with a confirmed diagnosis of dementia/medication review
Follow-up of diagnosis made privately with medication assessment needed
Referral for re-assessment of a previous MAS referral
Contact details
Who is the best person to contact to make the appointment? Please provide contact details
* Required
What is this person's relationship to the patient
Do we have consent to contact this person?
* Required
Yes
No
If yes, please provide a contact telephone number
Administrative information
Please note, initial contact will be made my telephone
What number(s) is it best to reach the patient on?
* Required
Has patient given consent to leave a message?
* Required
Yes
No
Has patient given consent for text messages?
* Required
Yes
No
Is an interpreter required?
* Required
Yes
No
If yes, which language?
Is the patient housebound?
* Required
Yes
No
Is the patient a wheelchair user?
* Required
Yes
No
Please list any disabilities
Is the patient known to any other services?
Are there any risks to staff which have been identified? eg. Lone-working, aggressive behaviour etc.
Has this referral been discussed with the patient, and/or their relative if they lack capacity?
* Required
Yes
No
Do you have lasting power of attorney?
Have any advance decisions been made?
History and examination
Please note if you have significant concern you can contact MAS on 0300 303 5342 to discuss the case over the telephone
Select your cognitive screening test
* Required6CIT MMSE GPCOG
What is your score?
* Required
Please describe concerns with memory problems and cognition eg. How long has there been concern? Are there any recent triggers?
* Required
Please confirm that you have completed a physical examination on the patient
* Required
Yes
No
Please detail any abnormal findings
Please confirm that other reversible causes of cognitive decline been excluded
* Required
Yes
No
Any additional information? (i.e. further information from family member / friend / carer / practice staff, vulnerability, any other stresses)
Weekly alcohol intake (in units)
* Required
Historical smoking status
Blood results (please append result) (FBC, B12, Folate, TFTs, U&E, Ca2+, LFTs, glucose or HbA1)
* Required
Medical history
Major problems (include start date and the problem)
Minor problems (include start date and the problem)
List of medication
Current medication (include dose and description)
Allergies (include start date and allergy or sensitivity)
Allergies (include start date and allergy or sensitivity)
