Primary Care Practitioner Assessment And Referral Form
Download a blank fillable Primary Care Practitioner Assessment And Referral Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Primary Care Practitioner Assessment And Referral Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Saskatchewan Spine Pathway Clinic
FAX to Regina: 306-766-7551
Primary Care Practitioner
Assessment and Referral Form
FAX to Saskatoon: 306-655-8951
Patient Information
/
/
INITIAL ASSESSMENT:
Name:
/
/
FOLLOW UP ASSESSMENT:
-
-
HSN:
Female
Male
Age:
HOME ADDRESS
CITY/PROVINCE
Address:
-
-
-
-
Phone:
Alt. Phone:
Back Specific History
1. Where has the pain been the worst? (Check one)
6. What is the overall level of disability?
Back Dominant
Leg Dominant
No Limitations
Mild Limitations- able to do most activities with minor modifications
2.
Does the pain stop, even for a moment?
Moderate Limitations – able to do most activities with modification
Intermittent
Constant
Severe Limitations – unable to perform most activities
3.
What are the:
7. Check
if Red Flags are present:
Aggravating Factors: __________________________________________
Indicates urgent surgical referral:
Possible Cauda Equina Syndrome
Relieving Factors:____________________________________________
Loss of anal sphincter tone/fecal incontinence
4. Is there a previous history of back problems?
Saddle anaesthesia about anus, perineum, or genitals
No
Yes. Describe:______________________________
Urinary retention with overflow incontinence
5. Has there been previous treatment or surgery for back problems?
No
Yes. Describe:______________________________
Back Specific Physical Exam
8. Movement: Produce typical pain
12. Reflex (conductive) Tests
Major Deep Tendon Reflexes
Pain produced on flexion
Pain produced on extension
Patella Reflex (L4)
Normal
Abnormal
Not Tested
9. Irritative Test: Looking to reproduce patient’s typical leg dominant pain
Achilles Reflex (S1)
Normal
Abnormal
Not Tested
a. Passive Single Leg Raise
Right
Positive
Negative
13. Motor (conductive) Tests
Left
Positive
Negative
a. L5
b. Passive Femoral Stretch Test
Ankle dorsi -flexion
Normal
Weak
Not Tested
Right
Positive
Negative
Not Tested
Hip Abductor
Normal
Weak
Not Tested
Left
Positive
Negative
Not Tested
Extensor Hallucis Longus
Normal
Weak
Not Tested
10. Lower Motor Function
b. SI
Saddle sensation
Normal
Abnormal
Flexor Hallucis Longus
Normal
Weak
Not Tested
Rectal (as needed)
Normal
Abnormal
Gluteus Maximus
Normal
Weak
Not Tested
11. Plantar Response
Flexor(normal)
Extensor (positive Babinski)
Diagnosis and Treatment
Pattern 1
Pattern 2
Pattern 3
Pattern 4
+ Pattern 5
Co-Morbidities:__________________________________________________________________________________________________________________
Comments:_____________________________________________________________________________________________________________________
Refer directly to surgeon if “Red Flags” are present, or to Spine Pathway clinic if “No Improvement” at follow up.
I hereby refer the above noted patient for referral to the Saskatchewan Spine Pathway Clinic and to a Spine Surgeon as appropriate.
If surgical referral indicated following Spine Pathway Clinic assessment, please refer to:
Next available surgeon
Specific surgeon*: _____________________
*Please note that if specific surgeon is selected, wait time may be longer than for next available surgeon.
I am referring to:
Community Rehabilitation
Chiropractor
Physio Therapist
Other___________________
Referring Practitioners Name: __________________________________ Discipline: _______________
Practitioner’s Address: ___________________________________________________________________
/
/
Practitioner’s Signature: _________________________________________ Date:
SPINE CLINIC PHONE NUMBERS: (306) 766-7025 Regina,
(306) 655-7644 Saskatoon
April 14, 2016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Rpd-41326 - Rural Health Care Practitioner Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department
Financial
Form Rpd-41326 - Rural Health Care Practitioner Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department
Financial
Related Categories
Parent category: Medical