Licenced under creativecommons.org licence - attribution, non-commercial, non-Derivative,
Transaid, (2012) - Some Rights Reserved
REFERRAL FORMS FOR CONDITION ASSESSMENT TOOL
About this tool: This form is to be used by trained health facility workers to measure the condition of referral
patients on arrival at their facility. This tool has been used in the past to evaluate the condition of pregnant
women on arrival at the health facility. (Note: Ethical approval may be required from the appropriate authorities
prior to data collection of this sort).
1. Unique Identification
Number:
2. Date:
3. Health Centre:
4. Name and signature of
Health Worker:
5. Patient’s name:
6. Patient’s address:
7. Time of Referral
requested:
8. Time of Departure:
9. Time of Arrival at Final
Referral Hospital:
10. Reason for referral:
11. Vital Signs Assessment:
<Insert Unique Identification Number>
<Insert Date>
<Insert Health Centre Name> (If Self-Referral to Hospital answer SELFREFERRAL)
<Insert Name and signature of Health Worker>
<Insert Patient’s name>
<Insert Patient’s address>
<Insert time of referral requested> ...Hours/...Minutes AM/PM
<Insert time of departure>
...Hours/..Minutes AM/PM
<Insert time of arrival at final referral hospital> ...Hours/ ... Minutes AM/PM
<Insert reason for referral>
Score
Resp rate
Neurology
Patient
responds
to ORGCS
4
Systolic
BP
Pulse
(BPM)
Urine
Output
Temp
<80
3
≤8
2
≤8
9-13
81-90
91-100
New
agitation
or
confusion
14
101-110
<40
41-50
<30
ml/hr
<35.1
<35.1-36
<10
ml/hr
1
0
1
2
3
A
(Alert)
15
V
(Voice)
P
(Pain)
U
(Unre
sp.)
111199
51100
36.138
>200
101-110
111130
38.138.5
≥38.6
>131
(Source: Royal United Bath Hospitals Trust,
UK:http://www.ruh.nhs.uk/about/policies/documents/clinical_policies/blue_clinical/Blue_776.pdf )
RESPS
<insert resp rate no.>
NEURO
<insert neuro no.>
BP
<insert BP no.>
PULSE
<insert pulse no.>
URINE
<insert urine output no.>
TEMP
<insert temp no.>
TOTAL
<insert total no.>
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Telephone: +44 (0)20 7387 8136
Email : info@transaid.org
www.transaid.org
Transaid Worldwide Services Ltd is registered in England as a company limited by guarantee.
Registered no 3511363. Registered charity no 1072105. Patron HRH The Princess Royal.