Camden and Islington Wheelchair Service

The Peckwater Centre

6 Peckwater Street

London

NW5 2TX

Tel: 020 3317 5040

Email:

Client Demographics:
Title: / Forename: / Surname: / Sex: Please select...FemaleIntersexMale
NHS No.: / Can the client speak English? Please select...YesNoNo - Interpreter RequiredNo - Carer/Relative to InterpretNon-Verbal
Date of Birth: / First
Language: / Urgency
Reason:
Home/Discharge Address:
(including Postcode) / Permanent Address
Temporary Address
Contact Details:
(Parents/Guardians) / Name: / Telephone: / Email:
Name: / Telephone: / Email:
School/Nursery Address:
Phone Number:
GP Details: / Name: / Phone:
Address (inc. Postcode):
IMPORTANT: The following GP details MUST be completed, otherwise the referral will be returned. Only clients registered with Camden/Islington CCG GP practices will be accepted by this service.
Safeguarding Details(if applicable)
Disability / Diagnoses
Please include the date of diagnoses wherever possible.
Disability / Diagnoses / Disabilities / Diagnoses:
(Please include any relevant reports e.g. recent assessments, current medication etc.)
Date and results of last HIP x-ray ( if relevant):
Date and results of last spinal x-ray ( if relevant):
Planned Surgery (Known operations / planned surgical interventions)
Reason for Referral – please complete either A or B:
A – New Referral: Client does not currently have an NHS provided Wheelchair.
Type of
Wheelchair Required: / Buggy
Attendant Propelled Wheelchair (A/P)
Self-Propelled Wheelchair (S/P)
Electrically Powered Indoor / Outdoor Chair (EPIOC)
Special Seating
Review of Needs
NB. The Wheelchair Service does not powered wheelchairs for outdoor only use.
Comments:
B – Review Referral: Client currently has an NHS/Private Wheelchair.
Reassessment Details:
(reason for reassessment) / Model and Accessories currently used: / NHS
Private
Comments/Reason for Reassessment:
Wheelchair Usage
Intended Usage: Indoor Outdoor Indoor/Outdoor Appointments Only Education
(please tick as many as required)
Time spent in Wheelchair/buggy at any one time: 1-3 hours ½ day Full Time
Will the client be sitting in the chair on transport?: Please select...YesNo - Client can transfer
Detail/Comments:
Referrer’s Details
Name
Profession Please select...Occupational TherapistOccupational Therapist AssistantPhysiotherapistPhysiotherapist Assistant
Address / Contact telephone
Email Address
Date Referral Completed
Would you like to be notified of an appointment with the Wheelchair Service? Yes No
Other professionals involved (i.e. OT/PT/Consultant)?
Please give details, including contact numbers:
Housing
Type:
House Flat Other State
Access:
Lift Stairs Ramp Restricted Access
Is there adequate turning space in all areas? (eg 1.2m)Yes No
Is client waiting re-housing? Yes No
Any relevant measurements or space restrictions to consider:
Measurements (incomplete referrals will cause delays)
/ Height:
Weight:
Please ensure the individual is seated on a firm surface and sitting as upright as possible
A – - Pelvic hip width
B – - Buttock/thigh depth
C – - Lower leg length
D – - Seat to axilla
Posture
Please provide detail of client’s current postural status:
In sitting / In supine
Head/Neck
Trunk/Spine(kyphosis, scoliosis, lordosis?)
Pelvis/hips (obliquity or rotation?)
Upper Limbs
Lower Limbs
Chailey level of ability:
GMFCS Level:
Is posture : Correctable Fixed
Tone:
Tone Management:
Function (please attach risk assessment if relevant)
Cognitive abilities:
Sensory Needs:
Behaviour:
Continence:
Respiratory :
Feeding:
Hand Function:
Mobility ( indoors and outdoors) :
Transfer method:
Orthoses (on issue/due):
Parents/Carers needs:
Referrer recommendation and clinical reasoning:
Direct Equipment Prescriptions: (standard buggies and manual wheelchairs)
Model required:
Do-buggy Attendant Propelled Wheelchair Self Propelled Wheelchair
Comments:
Cushion required:
Standard foam : Yes No
Thickness : 2” 3”
Contoured cushion:Yes No
Comments:
Accessories required (NB. Standard lapstraps are supplied with all wheelchairs & buggies)
Does client require any accessories? Yes No
Pelvic Belt? Yes No
Reason:
Standard tray
Reason( Trays are issued for postural reasons only):
Other:
NB. All other accessories will require an assessment by a wheelchair therapist.
Client Ethnicity (tick as applicable)
Prefer not to say
A)White
White
British
Irish
Greek or Greek Cypriot
Albanian excluding Kosovan
Kosovan
Any other White background – Specify if you wish
B)Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed Background – Specify if you wish
C)Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian Background – Specify if you wish
D)Black or Black British
Caribbean
African
Nigerian
Somali
Congolese
Any other African Background – Specify if you wish
Any other Black Background – Specify if you wish
E)Chinese or other Ethnic Group
Chinese
Any other Ethnic group – Specify if you wish

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