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 Year1921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 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 Year19711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Date admitted to referring facility * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Current Admission diagnosis: * Operative date, if applicable: Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20192020202120222023 Past medical history: * Date form completed: * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20162017201820192020202120222023 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:
