Camden and Islington Wheelchair Service

The Peckwater Centre

6 Peckwater Street

London

NW5 2TX

Tel: 020 3317 5040

Email:

Client Demographics:
Title: / Forename: / Surname: / Sex: Please select...FemaleIntersexMale
NHS No.: / Can the client speak English? Please select...YesNoNo - Interpreter RequiredNo - Carer/Relative to InterpretNon-Verbal
Date of Birth: / First Language:
Home/Discharge Address:
(including Postcode) / Permanent Address
Temporary Address
Contact Details:
(client) / Home: / Mobile:
Email:
Housing Status:
(tick all that apply) / Lives Alone With Family With Carers Sheltered Housing
Nursing Home Residential Home Other, please state…
Delivery Address:
(if different from above) / NB: If different address, the client must be at the address for delivery, to allow for adjustments and set-up.
Contact for delivery or interpreting: / Name: / Tel:
Relationship to the client: / Reason: Please select...DeliveryInterpretingBoth
Access / Safety: / Access Requirements?:
Potential risks to staff?:
Continuing Care?: / Please select...YesNoWith Panel / Care Package detail:
GP Details: / Name: / Phone:
Address (inc. Postcode):
IMPORTANT: The following GP details MUST be completed, otherwise the referral will be returned. Only clients registered with Camden/Islington CCG GP practices will be accepted by this service.
Reason for Referral – please complete either A or B:
A – New Referral : (Client does not currently have a Wheelchair)
Type of
Wheelchair Required: / Attendant Propelled Wheelchair (A/P)
Self-Propelled Wheelchair (S/P)
Tilt-In-Space Required? (TIS): Please select...YesNo
Electrically Powered Indoor Chair (EPIC)
Electrically Powered Indoor / Outdoor Chair (EPIOC)
NB. The Wheelchair Service does not powered wheelchairs for outdoor only use.
Comments:
B – Review Referral: (Client currently has a Wheelchair)
Reassessment Details:
(reason for reassessment) / Model and Accessories currently used: / NHS
Private
Comments/Reason for Reassessment:
Wheelchair Usage
Intended Usage: Indoor Outdoor Indoor/Outdoor Appointments Only Education Work Day Centre
(please tick as many as required)
Time spent in Wheelchair at any one time: 1-3 hours ½ day Full Time
Will the client be sitting in the chair on transport? Please select...YesNo - Client can transfer
Detail/Comments:
Disability / Diagnosis
Please include the date of diagnoses wherever possible.
Disability / Diagnosis / Disabilities / Diagnoses:
Please tick if the client has any of the following and provide detail:
Visual Impairment Cognitive Deficit Perceptual Deficit Learning Disability Other
Detail:
Does the client have past history of, or is at risk of developing DVT? Please select...YesNo
Detail:
Prognosis / Prognosis:
Has the client undergone, or is undergoing rehab or physiotherapy? Please select...RehabPhysiotherapyOther
Detail:
Mobility
Walks independently indoors
Walks with assistance indoors (with / without walking aid) Aid:
Unable to walk
Self-propels / punts / drives current wheelchair
Any other comments:
Falls
Camden Falls Team - 0845 900 0684 / Islington Falls Team - 020 7527 1501
Has the client had any falls in the past 6 months? Please select...YesNo
If yes, how many times/on what occasions has/have the fall(s) occurred?
Has the client been referred to the relevant falls team? Please select...YesNon/a
If no, please consider referring to the falls team – contact numbers above.
Details of falls group if already referred:
Transfers
How does the client transfer?: Please select...IndependentlyWith assistance of oneWith assistance of twoUnable to transfer
Method of transfer: Please select...StandingPivot TransferTransfer / SlideStanding HoistHoist
Comments:
Is a particular seat height required for transfers?:
Client moving cushion from wheelchair: Please select...IndependentAssistedUnknown
Pressure Care
Camden Integrated Primary Care – 0845 900 0684
Camden Tissue Viability Service – 0203 3168393 / Islington District Nursing Service – 0203 316 1111
Islington Tissue Viability Service – 0203 316 8393
Skin Integrity Information / Does the client have a CURRENT pressure area?: Please select...YesNoUnknown
If yes, where did the pressure area occur?: Please select...BedWheelchairOther
Details (incl. site, grade, treatment):
Are TVN/DNs involved? Please select...YesNo
If yes, please provide contact details:
If no, consider referring to the relevant TVN/DN service – contact numbers above.
Does the client have HISTORY of pressure areas? Please select...YesNoUnknown
If yes, where did the pressure area occur?: Please select...BedWheelchairOther
Details (incl. site, grade, treatment):
Is the client at risk of developing a pressure sore? Please select...YesNoUnknown
Pressure Area Score:
(if known, with dates) / Waterlow:
Walsall:
Pressure Relief / Can the client push up for relief for at least 30s? Please select...YesNoUnknown
Can the client lean forwards in the chair to relieve pressure for at least 30s? Please select...YesNoUnknown
Comments:
Continence / Is the client continent? Please select...ContinentUrinally IncontinentFaecally IncontinentDoubly Incontinent
Management/Detail:
Environmental Factors
Has a home visit been carried out? Yes No If possible, please send the report along with this referral.
Does the client live in a wheelchair accessible property? Yes No
Time spent in Wheelchair at any one time: 1-3 hours ½ day Full Time
Will the client be sitting in the chair on transport?: Please select...YesNo - Client can transfer
Detail/Comments:
Social Factors
Details of care package (if appropriate)
Place of employment (if appropriate)
Day Centre (if appropriate)
Transportation Method & Model
Detail/Comments:
Other Details
Is the user able to attend the Peckwater Centre for an appointment? Yes No
Will the user require ambulance support to attend clinic appointments? Yes No
Detail/Comments:
Referrer’s Details (Please note: clients who are new to the Wheelchair Service need to be referred by a Health Care Professional)
Name
Profession
Address / Contact telephone
Email Address
Date Referral Completed
**FOR GP USE ONLY** - Medical Consent to Self-Propel
In your opinion does the user have any medical conditions that may affect their ability to self-propel? Yes No
Detail/Comments:
If yes, please tick the relevant box below:
The client is NOT medically fit to manually self-propel a wheelchair.
The client is medically fit to self-propel indoors only or outdoors with supervision/standby assistance.
The client is medically fit to self-propel any distance, with no supervision or assistance required.
GP Signature Date
Client Ethnicity (tick as applicable)
A)  White
White
British
Irish
Greek or Greek Cypriot
Albanian excluding Kosovan
Kosovan
Any other White background – Specify if you wish
B)  Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed Background – Specify if you wish
C)  Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian Background – Specify if you wish
D)  Black or Black British
Caribbean
African
Nigerian
Somali
Congolese
Any other African Background – Specify if you wish
Any other Black Background – Specify if you wish
E)  Chinese or other Ethnic Group
Chinese
Any other Ethnic group – Specify if you wish

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