Occupational Therapy Services Outpatient Occupational

Patient name _______________________________ Contact person (name) __________________________ Contact person (Ph) ____________________________ Date of birth: YY _______ MM _____ DD _______ Address: ___________________________________ Phone: (H) _______________ (W) _______________ Family physician:____________________________ HCN : _________________ Exp. date _____________ HUN: ______________________________________

Occupational Therapy Services

Outpatient Occupational Therapy Referral n n n n n

Cobequid Community Health Centre Eastern Shore Memorial Hospital Musquodoboit V M Hospital QEII Health Sciences Centre Twin Oaks Memorial Hospital

869-6116 885-3619 384-4108 473-4628 889-4102

Fax: Fax: Fax: Fax: Fax:

865-6018 885-3210 384-3310 473-4872 889-2470

Date of referral (yyyy/mm/dd): __________________ Diagnosis/Prognosis: _____________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Relevant surgical intervention/date: ______________________________________________________________________ ______________________________________________________________________________________________________ Other relevant health concerns: __________________________________________________________________________ REASONS FOR REFERRAL _________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ (Check all that apply)

n n n n n

Upper extremity Management n Functional transfers n Work/School for ABI Splinting assessment n Seating/Wheelchair mobility n Post ABI education Self care / Self management skills n Kitchen safety n Community living skills Lymphedema (i.e. banking,shopping, transportation) n Home/Community Accessibility Education re: _______________________________________________________________________________________

CLIENT’S RISK FACTORS: (Check all that apply)

How recently? ________________________ n Falls: Frequency and number of falls _________________________ Location of falls________________________________________________________________________________ n Skin integrity concerns or pressure sores: Please elaborate: _________________________________________________ n New

n Existing

n Stage: ______________

Current treatment /Equipment _______________________

n Pain: Please elaborate: _______________________________________________________________________________ n Client living in unsafe situation: Please explain: ___________________________________________________________ PHYSICIAN SIGNATURE REQUIRED FOR: Acute Pre/Post Surgical Conditions, Acute Post Fracture REFERRAL SOURCE (Please print): Name: __________________________________________________________________ Signature: _______________________________________________________________ Phone number: __________________________________________________________

CD0117MR_09_09

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