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:	<<Doctor:Name>>	
Referring address:	<<Doctor:Full Address>>	
Referring phone:	<<Doctor:Phone>>	
Referring fax:	<<Doctor:Fax>>	
Provider number: 	<<Doctor:Provider Number>>	
Referral date:	<<Miscellaneous:Date (short)>>	

Patient Details 	
Patient name:	<<Patient Demographics:Full Name>>	
Date of birth:	<<Patient Demographics:DOB>>	
Address:	<<Patient Demographics:Full Address>>	
Home phone:	<<Patient Demographics:Phone (Home)>>	
Mobile:	<<Patient Demographics:Phone (Mobile)>>	
Medicare number:	<<Patient Demographics:Medicare Number>> <<Patient Demographics:Medicare Expiry Date>>	
DVA number: 	<<Patient Demographics:DVA Number>>	
Health Insurance:	<<Patient Demographics:Health Insurance>>	
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>> <<Operation:Procedure Sub-report - Supplied>>	
Past Medical History:	<<Clinical Details:History List>>	
Investigation Results:	<<Summary:Investigation Results (Selected)>>	
Progress Notes:	<<Summary:Progress Notes (Selected)>>	
Current Rx:	<<Clinical Details:Medication List>>	
Allergies:	<<Clinical Details:Allergies/Adverse Reactions>>	
Clinical Risks:	<<Clinical Details:Warnings>>	
Social Situation:	<<Clinical Details:Social History>>	
Proposed d/c dest.	<<Proposed d/c destination>>	
Infections status:	<<Infection Status>>	

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 <6m>>	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:	<<Previous Functional Status:>>	

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

Date:	<<Miscellaneous:Date>>	

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