BCHS Community Stroke Rehabilitation Team

Referral form(BCHS Stroke 02)

Bexley Community Health Services

Please ensure Screening Tool has been completed and all criteria met before sending referral

This service provides Physiotherapy / Speech and Language Therapy / Occupational Therapy rehabilitation with access toDietician /Psychology / Nursing as required

Title: Sex:malefemale
SURNAME:
First Name:
Date of Birth: NHS No:
Address:
Tel. No/s: / GP Name:
GP Address:
Does the client speak English? YesNo
If no, what is their first language?
Will an interpreter be required? NoYes
Does the person live alone? YesNo
Who will open the door?
Next of Kin - Contact name
Phone no:
Relationship to client:
Main Carer - Contact name
Phone no: / Visual Problems
Hearing Problems
Is the client having falls? No Yes
If yes, how often:
Does the client have a carer/care package?YesNo
Who provides care?
Is the carer managing? YesNo
Comments: (e.g. Note number of calls per day/week)
NOT REQUIRED IF THERAPY REPORT ATTACHED
PRIMARY DIAGNOSIS:
Date of Onset:
Presenting Problems:
Thrombolysed? Yes No
CT Scan result
RELEVANT PAST MEDICAL HISTORY: / Are other agencies involved with the client?YesNo
If yes, please state details below:
Name of contact:
Designation:
Tel No: Email:
Are there likely to be any safety issues when visiting? YesNo
If Yes, please explain

Referral form - continued (page 2) Current Level of Function

Patient Name: DOB:

Mobility & Transfers
Transfers (Tick 1)
Independent
Assistance from 1 & or Aid
Assistance from 2
Hoist
Bed Bound
Mobility (Tick)
Walking
Independently
Supervision / help from 1
Supervision / help from 2
Wheelchair
N/A
Pushed in a wheelchair
Self propelling independently
Positioning Regime in Wheelchair / Bed…. Y / N
Has own wheelchair Y/N
Risk of falls Y / N
Cognition & Communication
Level of communication (Please circle as appropriate)
Consistent Yes / No responses , Single word level, Sentences , Full phrases
Please Tick Yes No
Cognitive Problems
------
------
Perceptual Problems
------
Expressive Dysphasia
Receptive Dysphasia
Dysarthria / Swallowing & Carer information
Please Tick Yes No
Dysphagia
Oral Feeding
Nasogastric feeding
PEG feeding
Special Mattress
Urinary Catheter
Urinary Incontinence
Faecal Incontinence
Referral for SLT
SMART Goals:
1.
2.
3.
Referral for OT
SMART Goals:
1.
2.
3.
Referral for PT
SMART Goals:
1.
2.
3.
Rankin Score on Admission
Rankin Score on D/C:
Barthel on Admission:
Barthel on D/C:

Referral form - continued (page 3)

Patient Name: DOB

Any Additional Comments: / Rehabilitation INPUT REQUESTED:
Physiotherapy
Speech & Language Therapy:
Communication
Swallowing difficulties
Occupational Therapy
Self Care
Domestic Tasks
Cognition
Leisure
Community Access
Dietitian:
Enteral Feed
O.N.S
Other
Name of Referrer: (please PRINT)
Hospital / GP:
Tel No:
Fax No:
Email:
Signed:
Date of Referral:
PLEASE email to:
TEL: 020 8319 7138
FAX 020 8319 7106

Please provide as much information as possible

BCHS Stroke Team Referral form 02-04-2012