Rehabiliation Unit Pre-Admission & Referral Form 	
P: 07 3816 9213 | F: 07 3816 9212 | E: dayrehab.sta@ramsayhealth.com.au 	
Medical Objects ID: AS4305002SF	

Referral Details	
Referral for:	<Referral Type:>	
Referral to:	<Referral to:>	
Referring doctor:	<DrName>	
Referring address:	<DrAddress>	
Referring phone:	<DrPhone>	
Referring fax:	<DrFax>	
Provider number: 	<DrProviderNo>	

Patient Details 	
Patient name:	<PtFullName>	
Date of birth:	<PtDoB>	
Address:	<PtAddress>	
Home phone:	<PtPhoneH>	
Mobile:	<PtPhoneMob>	
Medicare number:	 <PtMCNo> <PtMCLine> <PtMCExpiry>	
DVA number: 	<PtDVANo> <PtDVACard>	
Health Insurance:	<PtInsFund> <PtInsNo>	
Third Party Insurance:	<Third Party Insurance>	
Third Party Company:	<Third Party Company>	Claim Number:	<Claim Number>	
NDIS Status:	<Patient is NDIS participant>	
NDIS Application:	<NDIS Application>	

Patient Clinical and Social Details 	
Diagnosis:	<Diagnosis>	
Surgery: 	<Details of Surgery, Surgeon & Date of Surgery>	
Past Medical History:	<SelectedPMH>	
Investigation Results:	<Ix>	
Current Rx:	<SelectedRx>	
Allergies:	<Reactions>	
Social Situation:	<SocialHx>	
Proposed d/c dest.	<Proposed d/c destination>	
Infections status:	<Infection Satus>	

Current Mobility Status, Level of Dependence, ADLS 	
Patient Weight:	<Patient Weight (kg)>	Mobility:	<Mobility>	
Mobility aid:	<Mobility Aid>	Mobility Distance: 	<Mobility Distance (m)>	
Transfers:	<Transfers>	Weight Bearing:	<Weight Bearing>	
Date of next review of WB status:	<WB Status Review Date>	
Cognition:	<Cognition>	MOCA/MMSE score:	<MOCA/MMSE Score>	
Falls risk:	<Falls Risk>	
No. Falls < 6months:	<No. Falls <6 Months>	No Falls current Adm:	<No. Falls current Adm>	
Bladder Continence:	<Bladder Continence>	Bowel Continence:	<Bowel Continence>	
Showering:	<Showering>	
Wounds:	<Detail Wounds>	
Diet:	<Detail Diet>	
Fluids:	<Fluids>	
Communication:	<Detail Communication:>	
Previous Function Status:	<Detail Functional Status>	

Rehabilitation Plan and goals	
Patient willingness and ability to comply:	<Patient Willingness and Ability to Comply>	
Rehab goals:	<Rehab Goals>	

Date:	<TodaysDate>	

Signature:	
_____________________	
Please fax completed referral to St Andrew's Ipswich Private Hospital on 07 3816 9212, email dayrehab.sta@ramsayhealth.com.au or send via Medical Objects ID: AS4305002SF	

Please send a copy of 1) Recent progress/admission notes 2) Medication charts 3) Pathology results/scans and 4) ECG results if applicable to this referral.	

Hospital Use 	
Assessment completed by: Name:	Signature:	Date:	
Accepted by VMO: Name:	Signature:	Date: 	

Rehabiliation Unit Pre-Admission & Referral Form 	
Reviewed 09/03/2022	
Approved by Claire Thurwood CEO 	
THIS DOCUMENT IS UNCONTROLLED IF PRINTED