Tel: 64716007 Fax: 64716062

Patient Referral form

Date of Referral: ___________________________
Referral Source : Specify
Hospital/Department ________________________
Polyclinic ________________________
G.P. ________________________
Home Nursing Foundation ________________________
Community Group ________________________
Family ________________________
Others ________________________

Referrer Information:

Name: ___________________________

Relationship to patient: ____________________
Telephone number: _________________
Aware of programme through: ______________
Subsidy level as computed by Means Test
75%
50% 25% 0%

PATIENT INFORMATION:

Patient’s Name : ___________________________________________________________
Date of birth:__________ Male /Female
IC No. _____________________________ Dialect: ______________ Race:____________
Patient’s Address : __________________________________________________________
____________________________________________________________________________
Telephone number : __________________ Is patient on PA? Yes /No
How can patient be contacted?
Contact person : ___________________________ Contact Nos : ___________________
Relationship to patient: ______________________ ____________________
Medical Data:
Medical Problems : __________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Current medical provider: (Be specific)
____________________________________________________________________________
____________________________________________________________________________
How does the patient currently get to the doctor? Include problems, if any.
___________________________________________________________________________
___________________________________________________________________________

Mobility Status:

Can get out of bed? Yes/No With/ without assistance?
If no, for how long? __________________________________
Can walk within the home? Yes/No With/ without assistance?
Can go to toilet? Yes/No With/ without assistance?
Can walk outside of home? Yes/No With/ without assistance?

Mental Status:

Confused? Yes/No Describe ________________________________________________
Reason for referral: _______________________________________________________
__________________________________________________________________________

Patient’s Medication:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________