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Post COVID syndrome MDT assessment referral

Post COVID Syndrome MDT Assessment Referral

Section

Mobility

Brief description of initial symptoms

Please select the relevant symptom(s):

Previous Management

(Please provide copies of all relevant information detailing care received, at the bottom of this form)

Please select the relevant option(s):
Did the patient require oxygen?
Does the patient still require oxygen?

Reasons for Referral

Please indicate reason(s) for referral:

Were any of the symptoms above present prior to their COVID illness?
Is the patient under the care of any other services post COVID-19?
Please provide copies of all relevant information detailing care received:
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