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3705225-53086000Northern Region Gender Dysphoria Service (NRGDS) Referral FormNRGDS, based at Walkergate Park Hospital, Newcastle is a service for people who experience persistent confusion and/or distress with their gender. This includes people who want to change physical aspects of their gender as well as those who do not. The service is available to people over the age of 17 who live in England.Please complete the form as fully as possible to ensure that the referral is accepted. Please note, when referrals do not originate from the patient’s General Practitioner (GP), the referrer must establish the support of the GP prior to referral. In making or agreeing to a referral, GPs are assumed to agree in principle to prescribe medication recommended by NRGDS and to carry out investigations required to manage hormone treatment within current NHS England guidelines.Date of referralClick here to enter a date.Patient detailsCurrent name:Click here to enter text.D.O.B.Click here to enter a date.Has their name been changed by Deed Poll or Statutory Declaration?Yes ?No ?Preferred pronouns:He/Him ? She/Her ?They/Them ? Other ?If other, please specify: Click here to enter text.Preferred first name:Click here to enter text.Birth assigned genderMale ? Female ?Current gender identity:Male ? Female ?Non-Binary ? Gender fluid ? Other ?Disorder of sex development (DSD) / Intersex recorded?No ?Yes ? If yes, please give details:Click here to enter text.NHS Number:Click here to enter text.Patient Contact DetailsAddress:Click here to enter text.Postcode:Click here to enter text.Landline Tel No.Click here to enter text.Mobile Tel No. Click here to enter text.Interpreter required?No ?Yes ? If yes, what language?Click here to enter text.Can patient attend independently?No ? Yes ? If no, please give details:Click here to enter text.GP detailsGP Name:Click here to enter text.GP Practice Name:Click here to enter text.GP Practice Address:Click here to enter text.GP Tel No.Click here to enter text.GP Fax No.Click here to enter text.GP Email:Click here to enter text.Referrer’s details (Only complete if referrer is not the patient’s GP)Referrer’s Name:Click here to enter text.Job title:Click here to enter text.Referrer’s Address:Click here to enter text.Referrer Tel No.Click here to enter text.Referrer Fax No.Click here to enter text.Referrer Email:Click here to enter text.Please provide us with detailed reasons for the referral.The referrer (if not the GP) may need to liaise with the GP for some of this information. Click here to enter text.Health HistoryPlease provide details of any mental health history, risk history, forensic history or substance misuse that you are aware of:Click here to enter text.Please provide details of any history of learning disability or developmental disorder (such as autism spectrum disorder or ADHD):Click here to enter text.Please provide any family history that you are aware of regarding physical health problems (DVT/PE/CVA/Heart Disease/Cancer/Diabetes) and mental health problems:Click here to enter text.Please provide medical history details (this may be a computerised print-out from GP record):ConditionDetailsConditionDetailsEpilepsyYes ? No ?Click here to enter text.DiabetesYes ? No ?Click here to enter text.DVT or PEYes ? No ?Click here to enter text.Gynaecological issuesYes ? No ?Click here to enter text.CVAYes ? No ?Click here to enter text.Physical Intersex conditionYes ? No ?Click here to enter text.Heart DiseaseYes ? No ?Click here to enter text.Previous surgeryYes ? No ?Click here to enter text.Breast CancerYes ? No ?Click here to enter text.AllergiesYes ? No ?Click here to enter text.HypertensionYes ? No ?Click here to enter text.OtherYes ? No ?Click here to enter text.Current HealthPhysical Health AssessmentDate of AssessmentClick here to enter a date.Height (m)Click here to enter text.Weight (kg)Click here to enter text.Waist (cm)Click here to enter text.BMIClick here to enter text.Blood PressureClick here to enter text.Pulse rateClick here to enter text.Smoker?Yes ? No ?If yes, details:Click here to enter text.Alcohol consumption?Yes ? No ?If yes, units p/w?Click here to enter text.Recreational drug use?Yes ? No ?If yes, details:Click here to enter text.Please detail any present health issues including mental health issues:Click here to enter text.Current NHS prescribed Medication including hormones and hormone blockers (this may be a computerised print-out from GP record):Name of MedicationDoseDurationClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Please detail any known non-NHS prescribed hormones and hormone blockers that the patient is taking:Name of MedicationDoseDetails (e.g. how sourced, private prescription, duration of taking). Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Please details any other agencies involved with the patient e.g. CMHT, Social Care:Click here to enter text.Please use the space below to tell us about any other information that you feel is relevant for us to know:Click here to enter text.Please return this form to:Northern Region Gender Dysphoria ServiceCumbria, Northumberland, Tyne and Wear NHS Foundation TrustBenfield HouseWalkergate ParkBenfield RoadNewcastle upon TyneNE6 4QDTel:0191 2876130Fax:0191 2876131Email: NRGDSAdmin@cntw.nhs.uk ................
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