Brain Injury Service Referral Form Page 2
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2FUNCTIONAL INFORMATION – ABI or Neuro
To be completed by Allied Health Team
Chair Sitting Tolerance:
Specify minutes: _________________________________
Participation Level:
Specify: On average, patient is able to participate in _________ therapy sessions / day, _________times / week for ____________minutes / session.
Rancho Los Amigos Cognitive Scale at present:
___________________________
Behavioural Issues:
No
Yes (If yes, please check where applicable and describe, listing interventions used):
Physical aggression
Verbal aggression
Self abuse
Inappropriate sexual behaviour
Wandering
Other (specify)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Communication:
Language expression: Intact
Dysarthria
Only able to express basic needs
Uses gesturing
Completely impaired
Language comprehension:
Intact
Follows basic instructions
Impaired _______________________________________________
Other comments: __________________________________________________________________________________________________________
Cognitive Status:
Not Tested
Intact
Impaired
Orientation
(specify):
Attention
(specify):
Memory (short term)
(specify):
Memory (long term)
(specify):
Carry-Over/New Learning
(specify):
Judgment
(specify):
Insight
(specify):
Frustration Tolerance
(specify):
Other
(specify):
Briefly describe the rehabilitation goals (Be specific — e.g. increased mobility, speech, community living skills, etc.)
PT Progress & Plan
OT Progress & Plan
SLP Progress & Plan
Form completed by:
(Include name/telephone/date)
ABI or Neuro Functional Section / December 2011
Page 2 of 2
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