Pressure Cushion Referral Form

Dorset Wheelchair Service

Pressure Cushion Referral Form

Clients Name: / NHS No:
Address:
Contact No: / GP Name:
Contact No:
Date of Birth: / Consent to Treatment:
Diagnosis: / Transfer Method:
Height: / Weight:
Reason for referral for cushion / Length of time spent sitting in wheelchair
Type of wheelchair / Seat size
Postural problems: e.g. sitting balance, pelvic orientation, and scoliosis.
Skin Condition: e.g. redness, sores?
Pressure assessment tool used and score:
Do they use a pressure relieving mattress? If so what type?
Do they use a pressure cushion on their armchair? If so what type?
Previous cushions tried and the reason why these are not suitable?
Continence:
Further assessment required?
Referrer Name: / Designation and Contact Details

Note: The pressure cushion provided by Dorset Wheelchair Service is for use in the wheelchair only.

October 2012