Client Initials:1
Date of Birth:
WHEELCHAIR REFERRAL FORM
Gloucestershire NHS Wheelchair Service
Independent Living Centre, Village Road, Cheltenham, GL51 0BY. Tel 01242 713900
Email:
Please complete all sections (starred fields (*) are mandatory; if not completed the form will be returned) and forward the form to above address.
This service only provides wheelchairs for clients who have a clinical need to use a wheelchair indoors for longer than 6 months (due to illness/disability).
For TEMPORARY LOANS, contact GIS Community Equipment Service: 01452 520438.
For clients usually able to walk indoors but requiring a wheelchair on a regular basis for outdoor use, please refer to the Occasional Wheelchair Service using the same contact details as above, or via an Accredited Nurse/Physiotherapist/Occupational Therapist.
CLIENT DETAILS / *NHS Number*Title / *Surname / *Forename
*Date of Birth / Ethnicity (e.g. British)
*Address
Email address
*Postcode / *Tel Number(s)
Mobile Number / Keysafe Number (if applicable)
for visits
*This address is: client’s own home/residential or nursing home/other (delete as appropriate)
Does client live alone? Yes/No / Does client have a regular carer? Yes/No / Tel Number
Name of carer/next of kin / Relationship
Address (if different)
Is the client a war pensioner whose mobility has been compromised by active duty?Yes/No
*Height of client / *Weight of client
A) Hip width (widest part when seated, see diagram)
B) Thigh length (back to knee crease when seated, see diagram)
*Client’s diagnoses and relevant medical history (past and present)
PHYSICAL/FUNCTIONAL ABILITIES
*Can the client walk indoors? Yes/No / What aid/support is required?
*Does the client have a history of falls? Yes/No / If ‘yes’, how many falls in the last year?
Does the client need trunk support when sitting? Yes/No / If ‘yes’ please specify
*Can client transfer independently? Yes/No / *What equipment/assistance is required?
*Is the client already using a wheelchair? Yes/No / Type of wheelchair (if known)
*What is the source of the wheelchair?
Previous NHS supply / GIS / Red Cross / Private / Unknown
*How often would the wheelchair be used?
Daily / 3 days or more per week / Less than 3 days per week
Will the client be transported in a vehicle while seated in the wheelchair? Yes/No
PRESSURE ISSUES
Waterlow score (if known) / /14 / 0-10
comfort / 10-14
low risk / 15-19
high risk / 20-45
therapeutic
*Does the client have any pressure problems (eg marking of the skin/sores)? Yes/No
*If ‘yes’, please give details (location, grade etc.)
Is the client currently using a pressure cushion? Yes/No
If ‘yes’, what type and size?
On average, how long will the client be sitting in the wheelchair during one day?hours
EQUIPMENT REQUIRED (PLEASE ANSWER EITHER SECTION A OR B)
A – Manual wheelchair(for clients who are unable to walk indoors)
*How would the wheelchair be moved?
Pushed by attendant / Pushed independently by client (who is medically fit to self-propel)
*Where would the wheelchair be used?
For indoor-use only / For indoor and outdoor-use / For outdoor use only
Please list any accessories/features you know of that might be needed on a manual wheelchair (eg stump board)
B – Powered wheelchair (only for clients who are unable to walk or self propel indoors)
*Where would the wheelchair be used? / For indoor-use only / For indoor and outdoor use
NB: (THE NHS DOES NOT PROVIDE OUTDOOR-ONLY POWERED WHEELCHAIRS)
*Does client have visual impairments? Yes/No / *If ‘yes’, please give details
*Has the client suffered an epileptic seizure in the last 12 months? Yes/No
*If ‘yes’, please specify
*In your opinion, is the client cognitively/perceptually able to, and mentally alert enough to operate a powered wheelchair safely? Yes/No
*If ‘no’, please specify why
*Please list any accessories/features you know of that might be necessary on a powered wheelchair (eg
stump board)
HOME ENVIRONMENT
Please comment on any features of the home environment that need to be considered (e.g. minimum door width/steps to access house). If a home visit has been completed, please enclose report. (Please continue on the ‘ADDITIONAL INFORMATION’ SECTION if needed)
OTHER DETAILS
*Name of referrer / *Profession
*Address of referrer
*Contact telephone number(s)
*Signature / *Date
*Name of GP / *Name of practice
Contact telephone number (if known)
Name of consultant (if applicable)
*Name of School/Day Centre Attended (if applicable)
Days attended / Telephone Number (s)
Key/Support Worker/Teacher(s)
*CONSENT TO REFERRAL (please select one or more)
Client or advocate/representative has consented to the referral being made to the Wheelchair Service.
Client understands that further information may be sought from health professionals involved to inform the assessment process.
Client agrees to receive appointment reminders via text messaging/email.Please ensure details have been provided on Page 1.
Client/advocate is not aware of the referral being placed.
ADDITIONAL INFORMATION
Please use this space to include any known names and contact details for other professionals involved (e.g. Physiotherapist, Occupational Therapist, Community Psychiatric Nurse, District Nurse) and any other relevant information that is not recorded on this form. Thank you.