Spinal Cord Service Referral Form

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FUNCTIONAL INFORMATION – Spinal Cord Injury
To be completed by Allied Health Team
Patient’s Name:
Cause of injury:
Premorbid function:
 Independent in ADL
 Dependent in ADL
Comments: ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Self Care:
Dressing:
 Independent
 Total assistance
 Partial assistance  Supervision only
Bathing:
 Independent
 Total assistance
 Partial assistance  Supervision only
Comments: ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Swallowing:
 Intact, regular diet
 Dental soft diet
 Minced diet
 Pureed diet
 Thickened fluids
Comments: ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Feeding:
 Independent
 Supervision required  Partial assistance  Total assistance  Tube feed
Comments: ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Transfers:
 Mechanical lift
 2 person
 1 person
 Supervision only  Independent
 On bed rest
Comments: ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Mobility aide:
 Standard Walker
 Rollator
 Wheelchair
 Cane
 Crutches
 2 Wheeled Walker
 Other (specify)
Comments: ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Wheelchair:
Requirements
 Manual
 Manual with tilt
 Power
 Power with tilt
Dimensions
 Hip width
 Upper leg length
 Lower leg length
Ambulation:
 Non-ambulatory
 2 person
 1 person
 Supervision only  Independent
 Distance (specify) ________________________
Comments: ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Limbs:
 Normal
 Left sided impairment  Right sided impairment
 Bilateral impairment
 U/E impairment
 L/E impairment
 Impaired coordination
 Reduced strength
 Other ________________________________________________________________________________________________
Comments: ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Spinal Cord Injury Functional Section / December 2011
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