Initial Referral Form Please complete as fully as possible (not all sections will be relevant) Question Title * 1. Patient Details Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number OK Question Title * 2. D.O.B DD/MM/YYYY OK Question Title * 3. Gender identity: OK Question Title * 4. Next of Kin (Name and Telephone Contact) OK Question Title * 5. Name of GP OK Question Title * 6. GP Surgery OK Question Title * 7. GP Surgery Address OK Question Title * 8. GP Surgery Telephone OK Question Title * 9. Name of Case Manager? OK Question Title * 10. Name of Solicitor OK Question Title * 11. Name of Prosthetic centre? OK Question Title * 12. Are you on Active Treatment? Yes No OK Question Title * 13. Reason for referral? Medical Assessment Prosthetic Assessment Orthotic Assessment Physiotherapy Assessment Counselling Service Occupational Therapy Other (please specify) OK Question Title * 14. How did you find out about us? Medical Referral Legal Referral Internet Other Media Word of Mouth Other (please specify) OK Question Title * 15. Amputation (if applicable) level or condition: Digit (finger) Hip disarticulation Knee disarticulation Orthotic requirement Partial hand Pre-amputation Symes Transfemoral Transhumeral Transradial Transtibial OK Question Title * 16. Cause: Clinical Negligence Trauma Vascular Other (please specify) OK Question Title * 17. Medical History - Describe briefly the background to your referral OK Question Title * 18. Smoker? Yes No OK Question Title * 19. Diabetic Type 1 Type 2 No OK Question Title * 20. Visual Impairment Yes No OK Question Title * 21. Hearing Impairment Yes No OK Question Title * 22. Unexplained weight loss Yes No OK Question Title * 23. Angina Yes No OK Question Title * 24. Rheumatic fever Yes No OK Question Title * 25. Heart murmur Yes No OK Question Title * 26. Blood pressure Normal High Low OK Question Title * 27. Bleeding/anticoagulant treatment Yes No OK Question Title * 28. Are you taking Steroids? Yes No OK Question Title * 29. Bronchitis Yes No OK Question Title * 30. HIV/Hepatitis/MRSA Yes No OK Question Title * 31. Alcohol Yes No OK Question Title * 32. Kidney disease Yes No OK Question Title * 33. Epileptic Yes No OK Question Title * 34. Liver disease Yes No OK Question Title * 35. Pregnant Yes No OK Question Title * 36. Heart attack Yes No OK Question Title * 37. Irregular heart beat Yes No OK Question Title * 38. Pace maker Yes No OK Question Title * 39. DVT or PE Yes No OK Question Title * 40. TIA / Stroke? Yes No OK Question Title * 41. TB Yes No OK Question Title * 42. Asthma Yes No OK Question Title * 43. Other OK Question Title * 44. Any surgery, musculoskeletal or orthopaedic injuries? (i.e. bone fractures,muscle injuries,ligament damage) OK Question Title * 45. Current Medication (list all medication including strength of tablet and number taken daily e.g Asprin tablet 75mg 1 per day) OK Question Title * 46. Allergies or objections (Medication, animal products and materials, e.g. nickel or glues) OK Question Title * 47. Do you require mobility equipment to get in and out of a chair? (for example, a hoist, sliding board, pivot table or walking frame) Yes No OK Question Title * 48. Any history of anxiety or depression Yes No OK Question Title * 49. Are you a Driver Yes No OK Question Title * 50. Please state any religious preferences or requirements OK Question Title * 51. Any Special requirements required to attend appointments? OK Thank you. When you attend our clinic you will be asked to sign consent forms, to complete your referral. OK DONE
