Sub-acute online referral

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 Year1917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019

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 Year19671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019

Date admitted to referring facility *

Day Day12345678910111213141516171819202122232425262728293031

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Year Year19971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019

Current Admission diagnosis: *

Operative date, if applicable:

Day Day12345678910111213141516171819202122232425262728293031

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Year Year20152016201720182019

Past medical history: *

Date form completed: *

Day Day12345678910111213141516171819202122232425262728293031

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Year Year20122013201420152016201720182019

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:

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