Cedars Rehabilitation Unit

NEURO REHABILITATION OUTPATIENT UNIT Linden Lodge Neuro Rehabilitation Unit, Nottingham City Campus, Hucknall Road, Nottingham NG5 1PB Tel: (0115) 993 6630 Fax: (0115) 962 8008 NEURO-REHABILITATION REFERRAL FORM The form should be completed by a person who knows the patient, e.g. a therapist or doctor. Please complete Section (1) in all cases and: Section 2 if you are referring for Physio Section 3 if you are referring for OT Section 4 if you are referring for SLT

Do you require a report when the patient is discharged? Yes No

Section (1)

PATIENT DETAILS Hospital Number:

Name: ______D.O.B____/____/____ Address: ______Tel: ______

Lives with: ______Main Carer: Contact Nos: ______

GP DETAILS HOSPITAL CONSULTANT

Name: ______Name: ______Address: ______Specialism: ______Hospital: ______Tel: ______

MEDICAL DETAILS

Details and date of onset/accident: please given information re. localisation of tumour/lesion, cause and severity of head injury (including length of PTA if known)

GCS score on admission: GCS score on discharge:

PRESENT MEDICATION RELEVANT PREVIOUS MEDICAL HISTORY

Please give details of dosage and review date e.g. diabetes, asthma, cardiac problems, epilepsy and any current hospital acquired infections SOCIAL HISTORY

Home situation/care package: e.g. CCA support, sitting service, day care (where and when)

Previous employment/education/literacy:

REASONS FOR REFERRAL

Please state specific rehabilitation goals/aims:

Please state which services the patient requires: Physio OT SLT

PSYCHOLOGICAL STATE

Please include any history of psychological problems, including anxiety, depression, behavioural difficulties or change in personalities

ANY OTHER INFORMATION WHERE IS THE PATIENT RECEIVING TREATMENT NOW AND WHAT IS THE LIKELY DISCHARGE DATE?

Present location: Likely discharge date:

DOES PATIENT NEED TRANSPORT TO ATTEND LINDEN LODGE? YES NO

If Yes, what kind of transport would be required?

Ambulance London Taxi Normal Taxi: Front Back

Will they need an escort? YES NO

Has patient been referred to other rehab services?

YES NO Details:……………….……………………………………………

CONTACT NAMES AND NUMBERS

OT Physio Clinical Psychology Speech and Language Therapy Social Worker Social Services Head Injury Care Manager Specialist Nurse (MS PD)

NAME:………………………………………… DESIGNATION:……………………………….………

SIGNED:………………………………… DATE:……………..…… TEL No…………………………..

Please return the completed form to the Neuro Rehabilitation Outpatient Team, Linden Lodge Neuro Rehabilitation Unit

PHYSIOTHERAPY REFERRAL Section (2)

Tone and Movement Muscle tone chart (continue on separate sheet if necessary) R/L R/L

Position F/B

Aids / Appliances Sensation Issued Ordered Referred to Orthotics Proprioception Details:……………………………………………….

Assessment of Gait

Current Problems and Treatment

Future Goals

Bladder and bowel function

Is Patient safe to be left unsupervised in waiting area? Yes No

Please give details, including any adaptations OCCUPATIONAL THERAPY REFERRAL Section (3)

ACCOMMODATION ACTIVITIES OF DAILY LIVING

Washing Dressing

Toileting (including transfers) Eating

Drinking Domestic

Leisure Driving

Other comments

WHEELCHAIR / SEATING

Please state model / cushion if appropriate, and source obtained

COGNITIVE FUNCTIONING

Please give details of any known cognitive problems e.g. intellectual memory, problem solving, reasonings, attention, visuo – perceptual, difficulties; including any formal assessments

PLANS FOR WORK

Previous employer, plans for voluntary work, etc

SPEECH AND LANGUAGE THERAPY

Section (4)

Has patient been assessed by a Speech and Language Therapist? YES NO If, YES please give details of where seen:______and by whom:______

Communication: If diagnosis known:

Dysphagia Dysphasia Dysarthria

Dyspraxia Cognitive-communication Disorder Facial Weakness

Understanding: Everyday conversation / Functional comprehension:

______

: Complex comprehension e.g. following directions, understanding abstract issues:

______

Any other details:

Speaking: Is the patient able to:

Speak clearly:______

Some difficulty with speech:______

Moderate difficulty:______

Unable to talk:______

Uses a communication aid / book / writing / /drawing / gesture:

______

Any other details:______

Social Communication Skills: (Cognitive – Communication Skills)

Please comment if any difficulties in this area: e.g. appropriacy of interaction with others, tone of voice, body language etc.

Reading:

Writing:

Hearing:

Swallowing Difficulties: YES NO

Has the patient been assessed by a Speech and Language Therapist for swallowing difficulties?

YES NO

Details about swallowing: ______

______