Patient details
Title
* Required
Forename
* Required
Surname
* Required
Home telephone number
Mobile number
Home address
* Required
Is the above your usual residential address?
* Required
Yes
No
If no, please provide usual address:
Patient NHS number
Patient RIO number (if applicable):
Date of birth
* Required
Ethnicity
* Required
Gender
* Required
Current location of patient
* Required
Home
Other
If other, please add full address and telephone number:
Date admitted (if appropriate)
GP name, full address and telephone number:
* Required
Next of Kin’s name, full address and telephone number:
* Required
Patients Occupation and employment status:
* Required
Social Worker’s name, telephone number and email address (if applicable):
Referrer's details
Title
* Required
Job title
* Required
Forename
* Required
Surname
* Required
Location/base
* Required
Consultant
* Required
E-mail address
* Required
Name and contact details: (PT, OT, SLT, Psychology)
* Required
Any additional information
Patient's condition
What is the patient’s:
Neurological diagnosis and relevant dates?
Brief Medical history?
Psychiatric history?
Current medications?
Please give details:
* Required
What is the main reason for referral and the patient’s current presentation?
* Required
Please note: Therapy input is required to complete this section.
What are the patient’s functional rehab goals for admission? Please provide details, e.g. Physical, cognitive.
* Required
Is the patient currently medically stable?
* Required
Yes
No
Is the patient on IVs?
* Required
Yes
No
Is the patient on oxygen?
* Required
Yes
No
All nutritional needs met by NG?
* Required
Yes
No
Please note: We do not accept referrals directly from critical care areas.
Does the patient require supervision?
* Required
Yes
No
If yes, what level of supervision?
Does the patient's level of consciousness fluctuate?
* Required
Yes
No
Comments
Is the patient’s behaviour a consequence of a brain injury and difficult to manage?
* Required
Yes
No
If yes, please describe the behaviour:
Is the patient displaying any of the following?
Agitation
* Required
Yes
No
Wandering
* Required
Yes
No
Physical aggression
* Required
Yes
No
Verbal aggression
* Required
Yes
No
Is the patient at risk of harm to self or others?
* Required
Yes
No
Please provide details of the nature and frequency of incidents:
Please indicate the closest description to patient’s status.
* Required
Alert and Orientated
Alert and Disorientated
Awake but not fully aware (which has lasted for longer than 4 weeks since the illness or injury)
If not conscious, please list medications with doses:
Has a referral to Walkergate Park been discussed with the patient and/ NOK and consent been given to refer?
Discussed with patient and/NOK
* Required
Yes
No
Consent provided
* Required
Yes
No
Lacks capacity
* Required
Yes
No
If patient lacks capacity, please enter the date and details of decision made:
Is the patient independently mobile?
* Required
Yes
No
If no, please enter method of transfer/aids:
Does the patient have pressure damage?
* Required
Yes
No
If yes, please enter grade and location:
Is the patient PEG or NG Fed?
PEG
* Required
Yes
No
NG
* Required
Yes
No
PEJ
* Required
Yes
No
If answer is yes to any of the above, please enter what it is used for, type and date of insertion:
Does the patient have a catheter?
* Required
Yes
No
If yes, please enter size and date it was last changed:
Does the patient have a tracheostomy? Please note Walkergate Park only accepts uncuffed tracheostomies.
* Required
Yes
No
If yes, please enter size, date it was last changed and level of intervention required.
Has decannulation been attempted?
* Required
Yes
No
If yes, please provide outcome and detail any known issues:
Can the patient be left unsupervised for any length of time?
* Required
Yes
No
If yes, please enter current level of supervision:
Does the patient have a history of drug/alcohol abuse?
Current
* Required
Yes
No
Historical
* Required
Yes
No
If yes, please provide further information:
Does the patient require a translator?
* Required
Yes
No
If yes, please specify language:
Has a referral been made to another service?
* Required
Neuro-rehab ward
Other ward
Community placement
If ‘other ward’ please specify speciality:
Please confirm outcome of referral:
