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Prosthetic Service Referral Form

Referral Details

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Location(Required)

Referral date(Required)

Reason for referral(Required)

Referral for prosthetic assessment

Referral for pre-amputation assessment

Not referred for prosthetic assessment due to the following reason:

Reason - not referred

If inpatient, please select location

If other inpatient location - please specify

Specify ward/department

Is patient aware of this referral?

Yes

ACC Information (if applicable)

Claim number

Date of injury

Case Manager

Patient Details

Patient NHI(Required)

Date of birth(Required)

Patient title

First name(Required)

Last name(Required)

Ethnicity(Required)

Patient gender

Other gender (specified)

Contact phone number (mobile preferred)(Required)

Email(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

General practice name

GP name

Alternative contact details

Alternative contact person - first name

Alternative contact person - last name

Relationship to patient

Relationship - other

Contact mobile number

Amputation details

Side

Left

Right

Extremity

Lower limb

Upper limb

Other amputation type

Amputation type

Select

Trans tibial (BK)

Trans femoral (AK)

Knee disarticulation

Hip dis-articulation

Proximal femoral focal deficiency (PFFD)

Ankle disarticulation/Symes

Hemipelvectomy

Partial foot

Partial toes/toes/multiple toes (specify toes):

Partial toes/toes/multiple toes (specify toes)

Upper Limb

Left side

Right side

Tick all that apply

Trans radial (BE)

Trans humeral (AE)

Elbow disarticulation

Shoulder disarticulation

Inter-scapular thoracic

Wrist disarticulation

Partial hand

Partial finger/multiple fingers (specify fingers and level):

Partial finger/multiple fingers (specify fingers and level)

Other amputation type

Left side

Right side

Other

PDDF/O'Connor Extension

Van Ness/rotationplasty

Unknown

Other:

Other

Cause of Amputation

Cause of amputation(Required)

Congenital

Diabetes

Infection

Tumour

Injury/trauma

Vascular

Other (specify):

Cause of amputation - other

Cause of injury

Date of amputation

Hospital

Surgeon

Health Considerations

Relevant medical history (tick all that apply)

Conditions

Impaired cognition (specify)

Other detail (specify)

Interpreter required

Interpreter language

Does the patient have a current infectious disease?(Required)

Yes (please specify)

Unknown

Infection - specify

Is the patient receiving dialysis?

Peritoneal

If yes, what are their treatment days?

Are there any safety considerations or support needs we should be aware of for this patient?(Required)

Select any that apply and make a note in the comment box

Support with communication and understanding is needed

There are factors that may cause distress or discomfort (e.g. environment, procedures, or interactions)

There are considerations that may impact safe care delivery (e.g. history of escalating behaviour, requires a support person, close monitoring)

There are specific approaches or strategies that work well (e.g. best approaches, things to avoid, successful de-escalation techniques)

N/A

Comment

Mobility prior to amputation/aids

Discharge plan

Referrals made

List any other referrals made (e.g. Peer Support Service)

Referrer's Details

Name(Required)

Role

Phone

Email address

Referring hospital department & ward

Same as inpatient ward/department

Please specify

Consultant (Health NZ | Te Whatu Ora only)

Please send me an email confirmation of this referral

Yes

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