Camden and Islington Wheelchair Service
The Peckwater Centre
6 Peckwater Street
London
NW5 2TX
Tel: 020 3317 5040
Fax: 020 7485 5306
Email: candi.wheelchairservice@nhs.net
Client Demographics:
Title:
Forename:
Surname:
Sex: Please select...
NHS No.:
Can the client speak English? Please select...
Date of Birth:
First Language:
Home/Discharge Address:
(including Postcode)
Permanent Address
Temporary Address
Contact Details:
(client)
Home:
Housing Status:
(tick all that apply)
Lives Alone
With Family
With Carers
Sheltered Housing
Nursing Home
Residential Home
Other, please state…
Delivery Address:
(if different from above)
NB: If different address, the client must be at the address for delivery, to allow for adjustments and set-up.
Contact for delivery or
interpreting:
Mobile:
Email:
Name:
Tel:
Relationship to the client:
Reason: Please select...
Access Requirements?:
Access / Safety:
Potential risks to staff?:
Continuing Care?:
Please select...
Care Package detail:
Name:
GP Details:
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.
Reason for Referral – please complete either A or B:
A – New Referral : (Client does not currently have a Wheelchair)
Type of
Wheelchair Required:
Attendant Propelled Wheelchair (A/P)
Self-Propelled Wheelchair (S/P)
Tilt-In-Space Required? (TIS): Please select...
Electrically Powered Indoor Chair (EPIC)
Electrically Powered Indoor / Outdoor Chair (EPIOC)
NB. The Wheelchair Service does not powered wheelchairs for outdoor only use.
Comments:
B – Review Referral: (Client currently has a Wheelchair)
Model and Accessories currently used:
Reassessment Details:
(reason for reassessment)
NHS
Private
Comments/Reason for Reassessment:
Wheelchair Usage
Intended Usage: Indoor
Outdoor
(please tick as many as required)
Indoor/Outdoor
Appointments Only
Time spent in Wheelchair at any one time: 1-3 hours
½ day
Will the client be sitting in the chair on transport? Please select...
Detail/Comments:
Education
Work
Day Centre
Full Time
Disability / Diagnosis
Please include the date of diagnoses wherever possible.
Disabilities / Diagnoses:
Please tick if the client has any of the following and provide detail:
Disability / Diagnosis
Visual Impairment
Cognitive Deficit
Perceptual Deficit
Learning Disability
Other
Detail:
Does the client have past history of, or is at risk of developing DVT? Please select...
Detail:
Prognosis:
Prognosis
Has the client undergone, or is undergoing rehab or physiotherapy? Please select...
Detail:
Mobility
2
Walks independently indoors
Walks with assistance indoors (with / without walking aid)
Unable to walk
Self-propels / punts / drives current wheelchair
Any other comments:
Aid:
Falls
Camden Falls Team - 0845 900 0684
Islington Falls Team - 020 7527 1501
Has the client had any falls in the past 6 months? Please select...
If yes, how many times/on what occasions has/have the fall(s) occurred?
Has the client been referred to the relevant falls team? Please select...
If no, please consider referring to the falls team – contact numbers above.
Details of falls group if already referred:
Transfers
How does the client transfer?: Please select...
Method of transfer: Please select...
Comments:
Is a particular seat height required for transfers?:
Client moving cushion from wheelchair: Please select...
Pressure Care
Camden Integrated Primary Care – 0845 900 0684
Camden Tissue Viability Service – 0203 316 8393
Islington District Nursing Service – 0203 316 1111
Islington Tissue Viability Service – 0203 316 8393
Does the client have a CURRENT pressure area?: Please select...
If yes, where did the pressure area occur?: Please select...
Details (incl. site, grade, treatment):
Are TVN/DNs involved? Please select...
If yes, please provide contact details:
If no, consider referring to the relevant TVN/DN service – contact numbers above.
Skin Integrity Information
Does the client have HISTORY of pressure areas? Please select...
If yes, where did the pressure area occur?: Please select...
Details (incl. site, grade, treatment):
Is the client at risk of developing a pressure sore? Please select...
Pressure Area Score:
(if known, with dates)
Waterlow:
Walsall:
Pressure Relief
Can the client push up for relief for at least 30s? Please select...
Can the client lean forwards in the chair to relieve pressure for at least 30s? Please select...
Comments:
Continence
Is the client continent? Please select...
Management/Detail:
Environmental Factors
3
Has a home visit been carried out? Yes
No
If possible, please send the report along with this referral.
Does the client live in a wheelchair accessible property? Yes
No
Time spent in Wheelchair at any one time: 1-3 hours
½ day
Full Time
Will the client be sitting in the chair on transport?: Please select...
Detail/Comments:
Social Factors
Details of care package (if appropriate)
Place of employment (if appropriate)
Day Centre (if appropriate)
Transportation Method & Model
Detail/Comments:
Other Details
Is the user able to attend the Peckwater Centre for an appointment? Yes
Will the user require ambulance support to attend clinic appointments? Yes
No
No
Detail/Comments:
Referrer’s Details (If Different to GP’s Details)
Name
Profession
Address
Contact telephone
Email Address
Date Referral Completed
**FOR GP USE ONLY** - Medical Consent to Self-Propel
In your opinion does the user have any medical conditions that may affect their ability to self-propel? Yes
Detail/Comments:
No
If yes, please tick the relevant box below:
The client is NOT medically fit to manually self-propel a wheelchair.
The client is medically fit to self-propel indoors only or outdoors with supervision/standby assistance.
The client is medically fit to self-propel any distance, with no supervision or assistance required.
GP Signature
Date
4
Client Ethnicity (tick as applicable)
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
5