Oxfordshire Wheelchair Service (OWS)
Oxford Centre for Enablement, Nuffield Orthopaedic Centre
WINDMILL ROAD, HEADINGTON, OXFORD OX3 7HE
REFERRAL FORM
Please note: Incomplete forms will be returned for completion.
Date of referral:
___________
Date of Birth: _____________
Name(in full):
___________________________
Title:
_____________
Address:
___________________________
Tel No:
_____________
___________________________________________ Post Code:
_____________
NHS Number:________________________________
Next of kin:______________________________________Tel________________________
Special Delivery Instructions: _______________________________________________
Level of Priority:
Urgent
Reason:
Required for discharge
Standard
Discharge Date (if relevant):
Relevant Medical Details (including drugs, any proposed action, e.g. surgery):
GP(name & initial):
______________________________
Address:
______________________________
______________________________________________
Tel No:
______________
Post Code: ______________
Reason for Referral:
Physical Information:
Height:
_________________
Weight:
_________________
Hip Width:
_________________
Thigh Length:
_________________
Calf Length:
_________________
Level of Mobility (including any equipment used):
Indoor:
Outdoor:
Transfer Method (including any equipment used):
Version 2.1.6.2 Edited by Jan Edwards, April 2015
Are there any specific factors about the client’s home (or other places where the wheelchair
will be used) that should be taken into consideration?
How often will the wheelchair be used?
Every day
More than once a week
Once a week or less
For how long will the wheelchair be used at any one time?
More than 6 hours
From 3 to 6 hours
Less than 3 hour
Where will the wheelchair be used most?
Indoors at home
Outdoors only
Indoors & outdoors
How will the wheelchair be propelled?
By the user
By an attendant
Both
Additional Information (e.g. fitness of attendant):
Category of Need (please tick one box only):
Totally dependent upon a wheelchair for mobility due to permanent disability
Totally dependent upon a wheelchair for a limited period occurring within a long term disability
Non-dependent, but requires a wheelchair for daily use
Non-dependent, but requires a wheelchair for 1-3 days per week throughout the year
RECOMMENDATIONS
Provision of Equipment
If you are a OWS registered assessor and you wish to recommend suitable wheelchair and/or
accessories please give as much relevant information as possible (e.g. wheelchair model, size, etc)
Wheelchair:
Accessories:
Pressure Distributing Cushion*:
*Please note: these may only by requested for totally dependent users
Version 2.1.6.2 Edited by Jan Edwards, April 2015
INFORMATION ON TISSUE VIABILITY*
*This information is required only if you are requesting a pressure distributing cushion.
Does the client have an existing pressure ulcer?
Yes:
No:
If yes, please give details of severity/grade and site of pressure ulcer(s):
Is the client at risk of developing a pressure ulcer?
Yes:
No:
If yes, please give details of potential problems:
MODIFIED WATERLOW ASSESSMENT
Build/Weight for Height
Average
Above average
Obese
Below average
0
1
2
3
Age
14-49
50-64
65-74
75-80
80+
1
2
3
4
5
Continence
Catheterised/continent
Occasionally incontinent
Incontinent of faeces
Incontinent of urine
Doubly incontinent
0
1
2
2
3
Appetite
Average
Poor
NG tub-fluids only
Anorexic
0
1
2
3
Visual Skin Type
Healthy
Tissue paper
Dry
Oedematous
Clammy
Discoloured
Broken spot
0
1
1
1
1
2
3
Tissue Malnutrition
Terminal cachexia
Cardiac failure
Peripheral vascular disease
Anaemia
Smoking
8
5
5
2
1
Ability to Relieve Pressure
None
Limited
Reasonable
Sex
Male
Female
5
3
1
1
2
Neurological Deficit
E.g. Diabetes
Motor/sensory
Tetra/paraplegia
MS/CVA
}
}
}
}
Medication
Cytotoxics or high dose
steroids/anti-inflammatories
4-6
4
Information on other Risk Factors(E.g. sitting posture, transfer technique etc):
Other Measures of Pressure Management Implemented:
Cushions Tried:
Version 2.1.6.2 Edited by Jan Edwards, April 2015
FURTHER ASSESSMENT
Further assessment required?
Yes
No
If Yes, please tick one or more boxes:
Non-powered wheelchair
Powered wheelchair
Postural Assessment
Pressure distributing cushion
Other (please specify)
Home visits are not normally offered. If you are requesting a home visit please provide the
following details:
a) A brief rationale:
b) Access information:
Please indicate intended means of transport to appointment (N.B: transport cannot be provided
by OWS):
DETAILS OF REFERRER (to be filled in by person completing the form).
Name:
___________________________________________
Profession:
___________________________________________
Contact Address:
___________________________________________
___________________________________________
Telephone Number:
___________________________________________
Availability:
___________________________________________
Registered Assessor Number:
___________________________________________
Signature:
_______________________ Date:
___________
Please return completed form to OWS Administration, The Oxford Centre for Enablement,
Nuffield Orthopaedic Centre Windmill Road, Headington, Oxford OX3 7HE, Fax: 01865-227294,
owsadministration@nhs.net (preferred route)
Version 2.1.6.2 Edited by Jan Edwards, April 2015