WDHS Sub-Acute Online Referral
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:
*
example@example.com
Phone:
*
Mobile:
*
If same as phone number above type 'same as above'
Patient details
Surname of patient:
*
Given name/s:
*
Date of birth:
*
-
Day
-
Month
Year
Age:
Weight:
*
Gender:
*
Address:
*
Marital Status:
Patient preferred phone number:
Religion:
Date of first hospital admission in this episode of care:
*
-
Day
-
Month
Year
Date admitted to referring facility:
*
-
Day
-
Month
Year
Current Admission diagnosis:
*
Operative date, if applicable:
-
Day
-
Month
Year
Past medical history:
*
Date form completed:
*
-
Month
-
Day
Year
Rehabilitation
Type of rehabilitation required:
Rehabilitation goals
*
Residential details
Lives with:
*
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 required by patient (prior to recent problems):
*
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
Has additional staffing been required?
*
Yes
No
Has there been any formalised cognitive testing?
*
Yes
No
Alert
*
Yes
No
Orientation
*
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 responsibility
Payment type:
Other:
Payment Type Number:
Submit
Print Form
Should be Empty: