ARC ADMISSION FORM
Patient's Name
*
First Name
Last Name
Date of Birth
*
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Gender
*
Male
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Non-binary or gender-diverse
Other
What pronouns do you use?
*
She/her/hers
He/him/his
They/them/theirs
Other
Primary Diagnosis
*
Date Diagnosed
Phone Number
*
-
Area Code
Phone Number
E-mail
Who is the preferred person to contact regarding appointments? (e.g client, next of kin, referrer)
*
What is the preferred method of contacting this person regarding appointments? (e.g email, text, phone call)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Other
Country
Next of Kin (name and relationship to you/participant/client)
*
Next of Kin contact number
*
Relation to Client (Mother, Partner, Sister)
*
MORE INFORMATION ABOUT YOUR REFERRAL
Reason for service requested
Physiotherapy
Occupational Therapy
Exercise Physiology
Specialist Disability Accommodation
Other
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Please highlight any known risks that therapists need to be aware of including behaviours - physical or environmental. Please state what measures are in place to manage these risks.
Type of funding
*
NDIS
My Aged Care
CTP/LTCS
WorkCover
Privately Funding
DVA Gold Card
Other
Type of NDIS Funding
*
NDIS Agency Managed
NDIS Planned Managed
NDIS Self Managed
NDIS Participant Number
*
NDIS Plan Start Date
*
-
Day
-
Month
Year
Date
NDIS Plan End Date
*
-
Day
-
Month
Year
Date
DVA / Claim / Identification Number
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GP INFORMATION
GP Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
E-mail
SPECIALIST INFORMATION
Specialist Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
E-mail
SERVICES AND HISTORY
Main Reason for attending ARC
*
What are your therapy Goals?
*
Expectations of therapy
*
Current Medication List
*
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Do you have any of the following Medical Conditions
*
Rows
Yes
No
Comments.................................
Heart Condition
Respiratory Condition
Neurological Condition
Surgery
Diabetes
Epilepsy
Current or past cancer
Current Infectious disease
Open wound or skin condition
Joint replacement
Recent change in medication
Bladder or bowel incontinence
Difficulties with vision
Difficulties with hearing
Poor appetite or nutrition
Dizziness or vertigo
Fall in the past 12 months
Anxiety
Depression
Pregnancy
Other
Other professionals involved in my care
Rows
Yes
No
Name of health professional
Physiotherapist
Occupational Therapist
Speech Pathologist
Case manager
Optometrist
Dietician
Chiropractor
Podiatrist
Orthotist
Other
Existing therapy/exercise program
Why did you choose our service?
Internet search
Someone told me it was great
NDIS Portal
NDIS Support Co-ordinator
Hospital referral
GP or Specialist referral
Other
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