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    Advance Referral Form 1

    Uploaded by

    Khairul Sc
    This document records information about a patient's injury history and current medical complaints. It notes the date and description of injury, whether imaging was done, and the suspected cause. It also lists the patient's primary complaint, relevant risk factors like their concussion, headache, and medical history, and current medications. The physician may note their diagnosis, any upcoming tests, and recommendations for treatment including referrals to other specialists.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Advance Referral Form 1

    Uploaded by

    Khairul Sc
    29 views1 page
    This document records information about a patient's injury history and current medical complaints. It notes the date and description of injury, whether imaging was done, and the suspected cause. It also lists the patient's primary complaint, relevant risk factors like their concussion, headache, and medical history, and current medications. The physician may note their diagnosis, any upcoming tests, and recommendations for treatment including referrals to other specialists.

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    advance-referral-form-1

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    This document records information about a patient's injury history and current medical complaints. It notes the date and description of injury, whether imaging was done, and the suspected cause. It also lists the patient's primary complaint, relevant risk factors like their concussion, headache, and medical history, and current medications. The physician may note their diagnosis, any upcoming tests, and recommendations for treatment including referrals to other specialists.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    29 views1 page

    Advance Referral Form 1

    Uploaded by

    Khairul Sc
    This document records information about a patient's injury history and current medical complaints. It notes the date and description of injury, whether imaging was done, and the suspected cause. It also lists the patient's primary complaint, relevant risk factors like their concussion, headache, and medical history, and current medications. The physician may note their diagnosis, any upcoming tests, and recommendations for treatment including referrals to other specialists.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Affix Patient Label Here

    Injury History Date of Injury: ___________________

    1. Injury Description _______________________________________________________________________

    ⬜ ⬜ ⬜
    _________________________________________________________________________________________

    ⬜ ⬜
    2. Was there evidence of injury? Yes No Unknown

    ⬜ ⬜ ⬜ ⬜ ⬜
    3. Was there imaging (i.e. CT, MRI) done? If yes, please attach reports/imaging. Yes No Type______

    ⬜ ⬜ ⬜
    4. Cause: MVA MVA v. Pedestrian Fall Assault Sports or Other (specify) Loss of

    ⬜ ⬜ ⬜
    Consciousness: Yes If yes, duration ____________ No Unknown
    Seizures: Were seizures observed? Yes If yes, details ________ No Unknown

    Patient’s Primary Complaint: ______________________________________________

    Risk Factors:

    Concussion History? (circle one) Y N Developmental History

    If yes, specify#:__________ Learning Disabilities

    Headache History? (circle one) Y N ADHD

    Patient _________ Family _________ Other developmental disorder

    Anxiety Sleep Disorder? (circle one) Y N

    Depression Please specify

    Other _____________________ If yes, what treatment if any


    List other medical conditions and all current medications (e.g., hypothyroid, diabetes)
    ___________________________________________________________________________________________________________
    ___________________________________________________________________________________________________________

    ⬜ ⬜ ⬜
    Physician Comments/Referral Specific Questions:
    Diagnosis: Concussion Yes No Other _____________________________________________
    Upcoming Medical Investigations/Tests: ___________________________________________________

    ⬜ ⬜ ⬜ ⬜
    Best practice is interdisciplinary treatment for concussion.
    Opt out of: OT PT AT CC Reasons ___________________________________________

    Physician Signature:

    Surrey: 108 - 9639 137A Street, Surrey, BC V3T 0M1


    Vancouver: Suite 110 – 1367 West Broadway Vancouver, BC V6H 4A7
    Phone: 604.428.8778 * Fax: 604.998.2257

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