Providence Wc Clinic Referral Form

3801 Lake Otis Pkwy., Ste. 100 Anchorage, AK 99508 (907) 212-2948 (907) 212-6310 Fax

WHEELCHAIR AND SEATING CLINIC REFERRAL FORM REFERRAL SOURCE Name: Agency: Address:

Phone: Fax:

PATIENT INFORMATION Name: Address:

Guardian/Caregiver: Date of Birth: Primary Diagnosis: Secondary Diagnosis: Height:

Day Phone: Evening/Alternate Phone: Primary Physician:

Weight:

INSURANCE INFORMATION Medicare #: Medicaid #: Preferred Provider Network/Tricare PCP:

Private Insurance: Yes__ No__ Phone:

SERVICE REQUESTED/PRIMARY CONCERN:  

Manual Wheelchair Evaluation Power Wheelchair Evaluation

 

Seating System Evaluation Scooter Evaluation



Other:____________________

CURRENT SERVICES: DME Vendor PT OT SP MD Other

MOTOR FUNCTION: Hand Dominance Right Arm/Hand Function Left Arm/Hand Function Lower Extremity Function Head/Neck Control

    

Right Full Full Full Full

    

Left Partial Partial Partial Partial

   

Nonfunctional Nonfunctional Nonfunctional Nonfunctional

MOBILITY:  Wheelchair (See Next Section) Distance:

  

Ambulation Independence  Without Device  Cane/Crutch  Independent   Walker  Brace ___________  Assistance Required <10 Feet Safety:  Safe Fall History: Yes__ No__ 10-150 Feet  Unsafe >150 Feet 

Dependent

WHEELCHAIR:  MANUAL Brand:_____________________ Method of Propulsion Level of Assistance  Arms  Legs  Independent  1Arm/1Leg  Other  Assist Needed  Dependent Rough Measurements Seat Width: _______” Seat Depth: _______”

Condition  Good  Fair

 

 POWER / SCOOTER Brand:______________________ Mode of Operation Level of Assistance  Right Joystick  Head Control  Independent  Left Joystick  Other  Assist Needed  Thumbs / tiller  Dependent

Poor Inoperable

Age  <1 Year  1-3 Years

 

3-5 Years >5 Years

Fit  

Too Big Too Small



Okay

Specific problems :

SEATING AND POSITIONING: Sitting Duration  <1 Hour  3-5 Hours  >10 Hours  1-3 Hours  5-10 Hours  Skin Problems Yes__ No__  Rash  Redness Surgery for skin breakdown Yes__ No__ Location: Date:

Able to relieve pressure Yes__ No__  Weight Shift  Manual Recline  Push-up  Manual Tilt  

 

Method Manual Tilt Power Tilt

Open Sores Scapes / Bruises Facility/Surgeon:

SEATING COMPONENTS Cushion Back Other

Type: Type: Type:

Condition: Condition: Condition:

Problems: Problems: Problems:

EDUCATION/VOCATION: Grade Completed________________ Occupation Accessibility/Sitting tolerance concerns:

Special Education? Yes___ No___ Employer:

Job/Duties:

VISION: Glasses Worn? Yes__ No__ Date of Last Exam:

Bifocals? Yes__ No__

Double Vision? Yes__ No__

COGNITION: Difficulty following directions Difficulty with memory Districtible

Yes__ No__ Yes__ No__ Yes__ No__

Does the patient use any other type of adaptive equipment or assistive technology (i.e. splints, communication device, computer, etc.)? ____________________________________________________________________________________________________________ Do you anticipate any future changes in patient’s condition (i.e. planned surgeries, new braces or wheelchair coming,etc.)? ____________________________________________________________________________________________________________

Thank you for referring your patient to The Wheelchair and Seating Clinic at Providence, and for providing this valuable information. We will be contacting the patient shortly for scheduling. Please remind your patient to bring any pertinent, currently used equipment. Please fax completed form to (907) 212-6310 Completed By: ____________________________________________________ Date: _________________