Keswick Care Home Patient Referral Form


This form should only be completed by Keswick Care Home staff on behalf of their residents, who are registered patients of Eastwick Park Medical Practice.

Please download, complete and attach these documents to this form before filling in and submitting this form:

A member of our clinical team may call you to discuss the problem.

Keswick Care Home Patient Referral

COVID-19 Screening

Do you have either:

a high temperature - This means you feel hot to touch on your chest or back (you do not need to measure your temperature) *
a new, continuous cough - This means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual) *
loss or change to your sense of smell or taste - this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal *
Have you been told by 111 to contact the practice? *
Do you live with someone who has had a high temperature or a new, continuous cough? If their symptoms started more than 14 days ago, click No. *
Please continue to fill out this form
Your symptoms suggest you might have Coronavirus (COVID-19). You should use the 111 online coronavirus service to find out what to do.

Situation

Observations

Background

Assessment

Recommendation

Completed by

*
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