Brain Injury Service Referral Form printable pdf download

FUNCTIONAL INFORMATION – ABI or Neuro

To be completed by Allied Health Team

Patient’s Name:

Date of injury/event:

_______ / _______ / _______

year

month

day

Nature/type of

 MVC

 MVC (motorcycle)

 MVC (on bicycle/pedestrian)

 Fall

 Assault

 Sporting

injury/event:

 Trauma-other (specify) _________________________________________________________  unknown

 Non-trauma (specify) ________________________________________________________________________

Glasgow Coma Score on admission

(if available): ___________

Previous history of ABI:

 No  Yes

Describe: __________________________________________________________

Seizures:

 No  Yes

Dates: ___________________ Describe: ________________________________

Loss of consciousness:

 No  Yes

Coma length: _______________________________________________________

Post Traumatic Amnesia:

 No  Yes

Duration: __________________________________________________________

Pre-Injury History of Substance Abuse:

 Yes  No  History not available Status on admission: ______________________

Current Substance Abuse:

 Yes  No  Not known

Substance Abuse Treatment Recommended:

 Yes  No

Neuro-ophthalmology consult conducted:

Visual field testing completed:  Yes  No

 Yes  No

Visual acuity testing completed:

 Yes  No

Include Results: ____________________________

Premorbid function:

 Independent in ADL  Dependent in ADL ______________________________

Self Care:

Dressing:

 Independent

 Total assistance

 Partial assistance

 Supervision only

Bathing:

 Independent

 Total assistance

 Partial assistance

 Supervision only

Swallowing:

 Intact, regular diet

 Dental soft diet

 Minced diet

 Pureed diet

 Thickened fluids

Feeding:

 Independent

 Total assistance

 Needs partial assistance

 Supervision required

 Tube feed (specify) _________________________________________________________________________

Transfers:

 Independent

 Mechanical lift

 2 person

 1 person

 Supervision only

 On bed rest

Transfer aide:

 Standard Walker

 Rollator

 Wheelchair

 Cane

 Crutches

 2 Wheeled Walker

 Other (specify)

Ambulation:

 Non-ambulatory

 2 person

 1 person

 Supervision only

 Independent

 Distance (specify) ________________________

Limbs:

 Normal

 Left sided impairment

 Right sided impairment

 Bilateral impairment

 U/E impairment

 L/E impairment

 Impaired coordination

 Reduced strength

 Other _____________________________________________________________________________________

ABI or Neuro Functional Section / December 2011

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Brain Injury Service Referral Form

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