August 21, 2014 Please note all questions marked with * are required fields.Referring facility Name of referring facility: * Name of referring medical consultant: * Position held: * Current ward: Current ward telephone number: * Preferred contact details Name of preferred hospital contact: * Email: Phone: * Mobile: * Patient details Surname of patient: * Given name/s: * Date of birth: * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Age: Weight: * Gender: * Address: * Marital Status: Patient preferred telephone: Religion: Date of first hospital admission in this episode of care: * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Date admitted to referring facility * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Current Admission diagnosis: * Operative date, if applicable: Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20172018201920202021 Past medical history: * Date form completed: * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20142015201620172018201920202021 Rehabilitation Type of rehabilitation required: General RehabilitationNeuro RehabilitationPainOrtho RehabilitationGEM Rehabilitation goals * Residential details Lives with: * Home AloneSpouse/Partner/FamilySupported ResidentialLow Level Residential CareHigh Level Residential CareOther Other Diet: Diet * FWD PEG NGT Diabetic Texture: Soft Cut up Mince Puree Pre morbid function (four weeks prior to recent problems)Please indicate with I, A or D. Indoor mobility: * I (Independent) A (Assist) D (Dependant) Transfers: * I (Independent) A (Assist) D (Dependant) Personal care: * I (Independent) A (Assist) D (Dependant) Continent urine: Yes No Continent faeces: Yes No Equipment, gait aid: * Current function Indoor mobility: * I (Independent) A (Assist) D (Dependant) Transfers: * I (Independent) A (Assist) D (Dependant) Personal care: * I (Independent) A (Assist) D (Dependant) Continent urine: Yes No Continent faeces: Yes No Please outline current equipment, gait aid currently required by patient: * Current cognition Have there been any concerns about the patient's current cognition?: * Yes No Has there been any formalised cognitive testing?: * Yes No Alert: * Yes No Orientated: * Yes No Does the patient have short term memory loss?: * Yes No Is the current cognitive function stable?: * Other Current Behaviour/Mood No issues: * Yes No Uncooperative: * Yes No Disruptive: * Yes No Aggressive: * Yes No Depressed: * Yes No Anxious: * Yes No Has additional staffing been required?: * Yes No Wanders: * Yes No Other: Referral consent Has referral been consented by patient/representative?: * Yes No Payment Responsibilty Select: - None -PatientPrivate Health FundTACWorkcoverVeteransOther (please specify) Other: Payment Type Number: Printer-friendly version