<p> 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</p><p>Do you require a report when the patient is discharged? Yes No</p><p>Section (1)</p><p>PATIENT DETAILS Hospital Number: </p><p>Name: ______D.O.B____/____/____ Address: ______Tel: ______</p><p>Lives with: ______Main Carer: Contact Nos: ______</p><p>GP DETAILS HOSPITAL CONSULTANT</p><p>Name: ______Name: ______Address: ______Specialism: ______Hospital: ______Tel: ______</p><p>MEDICAL DETAILS</p><p>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)</p><p>GCS score on admission: GCS score on discharge: </p><p>PRESENT MEDICATION RELEVANT PREVIOUS MEDICAL HISTORY</p><p>Please give details of dosage and review date e.g. diabetes, asthma, cardiac problems, epilepsy and any current hospital acquired infections SOCIAL HISTORY</p><p>Home situation/care package: e.g. CCA support, sitting service, day care (where and when)</p><p>Previous employment/education/literacy:</p><p>REASONS FOR REFERRAL</p><p>Please state specific rehabilitation goals/aims:</p><p>Please state which services the patient requires: Physio OT SLT</p><p>PSYCHOLOGICAL STATE</p><p>Please include any history of psychological problems, including anxiety, depression, behavioural difficulties or change in personalities</p><p>ANY OTHER INFORMATION WHERE IS THE PATIENT RECEIVING TREATMENT NOW AND WHAT IS THE LIKELY DISCHARGE DATE?</p><p>Present location: Likely discharge date:</p><p>DOES PATIENT NEED TRANSPORT TO ATTEND LINDEN LODGE? YES NO</p><p>If Yes, what kind of transport would be required? </p><p>Ambulance London Taxi Normal Taxi: Front Back </p><p>Will they need an escort? YES NO</p><p>Has patient been referred to other rehab services?</p><p>YES NO Details:……………….……………………………………………</p><p>CONTACT NAMES AND NUMBERS</p><p>OT Physio Clinical Psychology Speech and Language Therapy Social Worker Social Services Head Injury Care Manager Specialist Nurse (MS PD)</p><p>NAME:………………………………………… DESIGNATION:……………………………….………</p><p>SIGNED:………………………………… DATE:……………..…… TEL No…………………………..</p><p>Please return the completed form to the Neuro Rehabilitation Outpatient Team, Linden Lodge Neuro Rehabilitation Unit</p><p>PHYSIOTHERAPY REFERRAL Section (2)</p><p>Tone and Movement Muscle tone chart (continue on separate sheet if necessary) R/L R/L</p><p>Position F/B</p><p>Aids / Appliances Sensation Issued Ordered Referred to Orthotics Proprioception Details:……………………………………………….</p><p>Assessment of Gait</p><p>Current Problems and Treatment</p><p>Future Goals</p><p>Bladder and bowel function</p><p>Is Patient safe to be left unsupervised in waiting area? Yes No </p><p>Please give details, including any adaptations OCCUPATIONAL THERAPY REFERRAL Section (3)</p><p>ACCOMMODATION ACTIVITIES OF DAILY LIVING</p><p>Washing Dressing</p><p>Toileting (including transfers) Eating</p><p>Drinking Domestic</p><p>Leisure Driving</p><p>Other comments</p><p>WHEELCHAIR / SEATING</p><p>Please state model / cushion if appropriate, and source obtained</p><p>COGNITIVE FUNCTIONING</p><p>Please give details of any known cognitive problems e.g. intellectual memory, problem solving, reasonings, attention, visuo – perceptual, difficulties; including any formal assessments</p><p>PLANS FOR WORK</p><p>Previous employer, plans for voluntary work, etc</p><p>SPEECH AND LANGUAGE THERAPY</p><p>Section (4)</p><p>Has patient been assessed by a Speech and Language Therapist? YES NO If, YES please give details of where seen:______and by whom:______</p><p>Communication: If diagnosis known:</p><p>Dysphagia Dysphasia Dysarthria </p><p>Dyspraxia Cognitive-communication Disorder Facial Weakness</p><p>Understanding: Everyday conversation / Functional comprehension:</p><p>______</p><p>: Complex comprehension e.g. following directions, understanding abstract issues:</p><p>______</p><p>Any other details:</p><p>Speaking: Is the patient able to:</p><p>Speak clearly:______</p><p>Some difficulty with speech:______</p><p>Moderate difficulty:______</p><p>Unable to talk:______</p><p>Uses a communication aid / book / writing / /drawing / gesture: </p><p>______</p><p>Any other details:______</p><p>Social Communication Skills: (Cognitive – Communication Skills) </p><p>Please comment if any difficulties in this area: e.g. appropriacy of interaction with others, tone of voice, body language etc.</p><p>Reading:</p><p>Writing:</p><p>Hearing:</p><p>Swallowing Difficulties: YES NO </p><p>Has the patient been assessed by a Speech and Language Therapist for swallowing difficulties?</p><p>YES NO </p><p>Details about swallowing: ______</p><p>______</p>