Initial Referral Form Please complete as fully as possible (not all sections will be relevant) Patient Details Question Title * 1. Patient Details Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number OK Next of Kin (Name and Telephone Contact) Question Title * 2. Next of Kin (Name and Telephone Contact) OK Name of Case Manager? Question Title * 3. Name of Case Manager? OK Name of Solicitor Question Title * 4. Name of Solicitor OK Name of Prosthetic centre? Question Title * 5. Name of Prosthetic centre? OK Are you on Active Treatment? Question Title * 6. Are you on Active Treatment? Yes No OK Reason for referral? Question Title * 7. Reason for referral? Medical Assessment Prosthetic Assessment Orthotic Assessment Physiotherapy Assessment Counselling Service Occupational Therapy Other (please specify) OK How did you find out about us? Question Title * 8. How did you find out about us? Medical Referral Legal Referral Internet Other Media Word of Mouth Other (please specify) OK Medical History - Describe briefly the background to your referral Question Title * 9. Medical History - Describe briefly the background to your referral OK Smoker? Question Title * 10. Smoker? Yes No OK Diabetic Question Title * 11. Diabetic Type 1 Type 2 No OK Visual Impairment Question Title * 12. Visual Impairment Yes No OK Hearing Impairment Question Title * 13. Hearing Impairment Yes No OK Unexplained weight loss Question Title * 14. Unexplained weight loss Yes No OK Angina Question Title * 15. Angina Yes No OK Rheumatic fever Question Title * 16. Rheumatic fever Yes No OK Heart murmur Question Title * 17. Heart murmur Yes No OK Blood pressure Question Title * 18. Blood pressure Normal High Low OK Bleeding/anticoagulant treatment Question Title * 19. Bleeding/anticoagulant treatment Yes No OK Are you taking Steroids? Question Title * 20. Are you taking Steroids? Yes No OK Bronchitis Question Title * 21. Bronchitis Yes No OK HIV/Hepatitis/MRSA Question Title * 22. HIV/Hepatitis/MRSA Yes No OK Alcohol Question Title * 23. Alcohol Yes No OK Kidney disease Question Title * 24. Kidney disease Yes No OK Epileptic Question Title * 25. Epileptic Yes No OK Liver disease Question Title * 26. Liver disease Yes No OK Pregnant Question Title * 27. Pregnant Yes No OK Heart attack Question Title * 28. Heart attack Yes No OK Irregular heart beat Question Title * 29. Irregular heart beat Yes No OK Pace maker Question Title * 30. Pace maker Yes No OK DVT or PE Question Title * 31. DVT or PE Yes No OK TIA / Stroke? Question Title * 32. TIA / Stroke? Yes No OK TB Question Title * 33. TB Yes No OK Asthma Question Title * 34. Asthma Yes No OK Other Question Title * 35. Other OK Any surgery, musculoskeletal or orthopaedic injuries? (i.e. bone fractures,muscle injuries,ligament damage) Question Title * 36. Any surgery, musculoskeletal or orthopaedic injuries? (i.e. bone fractures,muscle injuries,ligament damage) OK Current Medication (list all medication including strength of tablet and number taken daily e.g Asprin tablet 75mg 1 per day) Question Title * 37. Current Medication (list all medication including strength of tablet and number taken daily e.g Asprin tablet 75mg 1 per day) OK Allergies (List all medication and substances e.g. nickel, that causes allergies to you) Question Title * 38. Allergies (List all medication and substances e.g. nickel, that causes allergies to you) OK Any history of anxiety or depression Question Title * 39. Any history of anxiety or depression Yes No OK Are you a Driver Question Title * 40. Are you a Driver Yes No OK Any Special requirements required to attend appointments? Question Title * 41. 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
