Spinal Cord Service Referral Form Page 2
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2FUNCTIONAL INFORMATION – Spinal Cord Injury
(cont’d)
To be completed by Allied Health Team
Patient’s Name:
Orthosis Type:
Collar
Wear at all times
When up in chair
As needed
Type
Duration of use
Brace
Wear at all times
When up in chair
As needed
Type
Duration of use
AFO
Wear at all times
When up in chair
As needed
Type
Duration of use
Other splints
Wear at all times
When up in chair
As needed
Type
Duration of use
Participation Level:
Specify: On average, patient is able to participate in _________ therapy sessions / day, _________times / week for ____________minutes / session.
Sitting Tolerance
Full
Limit
N/A
Restrictions/ Duration _____________________
Communication:
Language expression: Intact
Only able to express basic needs
Uses gesturing Completely impaired
Language comprehension: Intact Follows basic instructions
Impaired ___________________________________________
Comments: ____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Cognitive Status:
Not Tested
Intact
Impaired
Attention
(specify):
Able to follow instructions
(specify):
Memory (short term)
(specify):
Memory (long term)
(specify):
Carry-Over/New Learning
(specify):
Judgment
(specify):
Insight
(specify):
Other
(specify):
MMSE Score: ______
If did not/unable to complete, please explain:
Briefly describe the rehabilitation goals (Be specific — e.g. increased mobility, speech, community living skills, etc.)
PT Progress & Plan
OT Progress & Plan
SLP Progress & Plan
Form completed by: (Include name/telephone/date)
Spinal Cord Injury Functional Section / December 2011
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