Private and Confidential

PRESSURE CUSHION REFERRAL FORM

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To be completed by a G.P., District Nurse or Therapist. Please send the completed form to the relevant Wheelchair Assessment Service:

KCHT Wheelchair Service
Administration Team
Norman House
Beaver Business Park
Beaver Road
Ashford. TN23 7SH / Tel: 0300 7900128
Please e-mail the completed form to:

Service Hours - 09:00 to 17:00 Monday to Friday
DO NOT USE - INTERNAL USE ONLY
Ashford Heathside Aylesham Canterbury Medway Dartford
DO NOT USE - INTERNAL USE ONLY
NHS No:

*Please complete all boxes to avoid unnecessary delays*

Client Details
Title: Mr / Mrs / Miss / Ms / Master OTHER :
Forenames: Surname:
Date of Birth:
Full client postal address:
Postcode: / Alternative Contact/Address/Details:
Name & Relationship to Client:
Address/Details:
Postcode:
Telephone No:
Mobile No:
E-Mail: / Telephone No:
Mobile No:
E-Mail:
GP Name:
Address: Telephone Number:
Nature of disability / any relevant information:
Patient Height/Weight: Height (cm): Weight (Kg):

History of Pressure Area(s)

1 / Skin Condition:
No Problem Red Grazing / Broken Areas Open Sore
2 / Please specify grade of pressure sore: (Refer to wound classification sheet)
Grade:
3 / Please specify Waterlow score: (refer to Waterlow score chart)
Score:
4 / Site of current pressure sore(s):

5 / How long has the problem been present?
Less than 1 Week 1-4 Weeks More than 4 Weeks
Re-occurring problem Please specify:
6 / Where was the client when the pressure sore occurred?
Home Hospital
What were the factors contributing to the tissue damage/ pressure sore?
7 / Current treatment: (Please indicate any medications, dressings or surgical treatment and frequency of intervention)
8 / Does the client use a pressure relieving mattress? Yes No
If Yes please specify type:
9 / Time spent in the wheelchair per day? Hrs
(please note variations such as day centre attendance, longest time in chair in one session)
10 / Is the client able to carry out pressure relieving techniques whilst in the chair? Yes No Method:
11 / Transfer Method:
Stand Sliding Board Hoist-type:
No. of transfers per day?
12 / Is height of cushion important for transfers? Yes No
Height of cushion required?
13 / Client’s continence status?
Continent Double incontinence Catheter
Occasional Accident / urinary incontinent issues with continence products
14 / Cushions used at present? / Reason why cushion no longer suitable?
Previous Cushions Tried (if known)? / Reason why suitable?
Name of Referrer (please print):
Designation & Employing organisation:
Contact Details:
Telephone Office: Mobile: Email:
Signature: Date:

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Incomplete forms will be returned and may result in a delay to the provision of a wheelchair.