Referral Information and Screening Form Patients Name First Name Last Name Date of Birth Address Address 1 Address 2 City State/Province Zip/Postal Code Country Telephone numbers Email GP or Consultant name and address If appropriate name and contact number of Parent / Guardian / Key worker Present condition/ diagnosis Past medical history Medication names and dosage Is there a DNACPR (Do Not Attempt CPR) declaration in place? No Yes (if so documentation must be provided) What are the reasons for / goals of aquatic physiotherapy eg. improving movement, strength, function, pain management? Screening Information - Please complete all boxes Fear of water None Mild Severe Mobility Independent Using walking aid/s Wheelchair user Weight-bearing status Full Partial Non Transfers eg. level chair to chair, chair to standing, floor to chair Independent With assistance Fully dependent Personal care eg. dressing Independent With assistance Fully dependent Method of pool entry and exit Steps Chair hoist Plinth hoist Sling hoist Unknown Contraindications If any of the following answers are yes aquatic physiotherapy will not be appropriate Diarrhoea and vomiting within 48 hours * No Yes Medical instability following an acute episode eg. MI, CVA, DVT, PE, Status Asthmaticus without medical clearance * No Yes Uncontrolled cardiac failure with symptoms of progressive worsening of exercise tolerance, or shortness of breath at rest over the previous 3-5 days, or nocturnal paroxysmal dyspnoea * No Yes Unstable angina with symptoms of prolonged (>20 mins) angina at rest, new onset, increased frequency, or might not respond to GTN * No Yes Uncontrolled medical condition eg. epilepsy or diabetes IF NO MEDICAL MANAGEMENT PLAN IN PLACE * No Yes Acute systemic illness with associated pyrexia (increased temperature >38 degrees C) within last 24 hours eg. TB, flu or viral infection * No Yes Weight in excess of 165 kg or 26 stone * No Yes Precautions If any of the following answers are yes it would not prevent aquatic physiotherapy but it is important for the therapist to be aware of Compromised immune system eg. cancer, HIV, MS * No Yes Impaired skin integrity eg. open wounds, during or post radiotherapy, altered sensation No Yes Incontinence (urinary or faecal) * No Yes Behavioural problems * No Yes Uncontrolled blood pressure * No Yes Invasive lines / tubes eg. P.E.G., IV, catheters, Central or PIC * No Yes Widespread MRSA * No Yes Impaired vision or hearing * No Yes Pregnant * No Yes Transdermal patches * No Yes Any other relevant information Form completed by Self Physiotherapist GP Consultant Other Name, contact number and email address * Thank you
