Transcription of Date Accepted: Referral/Assessment Form Date …
1 Date Referred: .. Date Assessed: .. Patient Label Date Accepted: Referral/Assessment form .. For use by both those making referrals and RTRC Personnel. Date Admitted: Please provide as much information as you can.. Referrer/Assessor (print): Hospital: Ward: Role/Designation: Telephone: Pager: Medical History: Current (include dates) Medication: .. Medical History: Past (including alcohol, smoking and drugs, allergy and history of hospitalisation) .. Level of function prior to current health problem: (Physical, ADL, Social, Vocational): Driving Car.
2 Family & Social Supports: Who provides care: .. Next Of Kin/Guardian: ..Family Member Present at assessment Yes No Describe Home/House/Access: .. CURRENT FUNCTIONAL LEVEL. Physical: Transfers Independent Supervised Dependent [Assistance-One Person Two People ] Hoist Weight Bearing Status Full Weight Bear R L Partial Weight Bear R L Non-Weight Bear R L. Walking Independent Supervised Dependent [Assistance-One Person Two People ] Unable Aids: .. Stamina Good Fair Poor Comments:.. 1. Self care: Eating Independent Supervised Needs Assistance Showering Independent Supervised Needs Assistance Dressing Independent Supervised Needs Assistance Toiletting Independent Supervised Needs Assistance Continence Urine: Yes No Catheter Present Faeces Yes No Elimination Problems.
3 Cognitive & Behavioural function: Orientated: Yes No Appropriate: Yes No Confused: Yes No Agitated: Yes No Impulsive: Yes No Probable Wandering Memory: Intact Short Term Memory: Yes No Intact Long Term Memory: Yes No Mini Mental State Examination: .. For ABI patients- Post Traumatic Amnesia: Yes No Duration: .. Initial Glasgow Coma Score: .. Comments: .. Communication: l Language ..Interpreter required Yes No Ethnicity .. Normal Comprehension: Yes No Normal Expression: Yes No Communication Aids: Glasses Reading Glasses Distance Hearing Aid Other.
4 Comments: .. Swallowing Needs assessment : Yes Naso-Gastric Tube: Yes PEG: Yes Tracheostomy: Yes Diet: .. Modification:.. Fluids: ..Texture:.. Dietary Preferences: .. Wounds/Pressure areas/Skin care: .. Key Issues & Rehabilitation Plan: .. Confirm Discharge Destination & Telephone Number: .. Additional Comments: .. Admit Yes No Proposed Admission Date: .. Time Frame for Rehabilitation:.. Therapy team: ABI NEURO ORTHO SPINAL AMPUTEE. 7 Day Ward CRP Level 1 Level 2. Assessor's .. 2. 3.
