Hip and Knee Replacement Referral Form

1 Hip and knee Replacement Referral09884(Rev2019-03)Reason for ReferralWhat is the primary reason you are referring this patient?Type of Problem oPrimaryoRevisionDuration of Symptomso3 - 6 monthso6 - 12 monthsoYearsoOther(specify)Is this a WCB claim? oNooYes, specify claim numberWill you be assigning the patient to the next available surgeon?oNo, specify surgeon name (last, first)oYesPlease print, complete and return this form by fax to the appropriate clinic below. Attach the following with thecompleted form <Relevant medical history/EMR Record <X-ray report -MRI is not required for this referraloX-ray reports attachedKnee: AP weight bearing, lateral of knee with knee flexed, SkylineHip: AP pelvis centered at pubis, AP and lateral of proximal half of affected femurPatients must be on appropriate non-surgical treatment prior to evaluation( medication, physiotherapy, walking aids,shoe inserts).Primary Affected Joint(s) aRightLeftBilateralHipKneeSide APrevious Orthopaedic SurgeriesHas the patient undergone anyprevious orthopaedic surgeries?

2 ONooYes, completeSurgerySurgeonYearIs the patient currently controllingjoint pain with medication? oNooYes, completeoNarcoticsoOver the counteroNSAID/COXIB\oOther (specify)CommentsHeight cmWeight kgBMI Calgary DowntownFax - PrairieFax - DeerFax - South Health CampusFax - - - - HatFax - - - One Hip and knee Replacement Referral09884(Rev2019-03)Side BReferring Clinician Information (complete or use practice stamp below)NamePRACIDP ractice Stamp(if applicable)AddressPhoneFaxSignatureDate (yyyy-Mon-dd)Check appropriate boxesNoneMildModerateSeverePain on motion ( walking, bending)Pain at rest ( while sitting, lying down, or causing sleep disturbance)Other functional limitations ( putting on shoes, managing stairs, sitting to standing,sexual activity, bathing, cooking, recreation or hobbies)Abnormal findings on physical exam related to most severely affected joint( deformity, instability, leg length difference, restriction of range of motion on exam)

3 Highest level of walking supports(for the affected joint that patient currently uses to carry out usual activities work, leisure) oNone/OrthoticsoBrace/CaneoCrutches/Walk eroWheelchairHighest level of medication to manage affected jointoPRN pain medication oRegularly-scheduled medication use oMaximum medical therapy appropriate for patientAbility to walk without significant painoOver 5 blockso1-5 blocksoLess than 1 blockoHousehold ambulatorThreat to patient role and independence in society ( ability to work, give care to dependents, live independently) Must relate to affected jointoNot threatened but more difficult oThreatened but not immediately oImmediately threatened or unableRate the level of medical complexity of the patient(based on number and/or severity of key comorbid conditions, excludinghip/ knee condition)oNo medical problemsoCurrent mild medical problems or past significant medical problemsoModerate medical disability or morbidity/requires first line therapyoSevere/constant significant disability/ uncontrollable constant medical problemsoExtremely severe/immediate treatment required/end organ failure/severe impairment of functio