The Scottish Referral Pathway for Consideration of Funding
The Scottish Referral Pathway for Consideration of Funding
The Scottish Referral Pathway for Consideration of Funding
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For Paediatric Cases:Anaesthetic required: YES / NO / UNCERTAINMain carer(s):Other siblings in family (gender and ages):Family members (including ages) who will need to travel and lodge with patient:History synopsisSymptoms -Date <strong>of</strong> first symptomDiagnosis -Operations -Date <strong>of</strong> diagnosisDate <strong>of</strong> 1st operationProcedureDate <strong>of</strong> 2nd operationProcedureClinical Summary(include Past Medical History)Clinical conditionNeurological deficitsMobilityCommunication abilityOverall per<strong>for</strong>mance status WHO / ECOG PS 0 1 2 3(scale shown below)(delete as appropriate)10
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