ABI Community Stroke Programme Referral Form ABI Community Stroke Programme Referral Form Fields marked with an * are required 1. Client Details 1. Client Details Client First Name: * Client Surname: * Client Date of birth: * National Health Index (NHI) number: * Client Ethnicity: Client Phone number: * Client Address: * Client Email: * Client’s First Language: * Interpreter required: Yes No Alternative Contact Person: Relationship to the Client GP/Primary Health Care Provider contact details: 3. Referrer Details 3. Referrer Details Referrer name: * Referrer Service: Referrer Email: * Referrer phone: * 2. Stroke Programme Details 2. Stroke Programme Details Does the client meet the following criteria for entry into the stroke programme: * New Zealand Resident Stable medical condition (e.g. controlled blood pressure) Safe in a group setting where distant supervision is provided once set-up with an exercise Independent toileting or will be accompanied by a carer to help with this Can get from a sitting position to standing without hands-on assistance Able to understand simple verbal instructions that are supported with gesture or demonstration Able to tolerate a group setting without becoming distraction Tolerate one hour of low-level physical activity Commit to an eight week programme, two days a week Details of stroke: (inc. date of stroke, main symptoms, most recent hospital admission related to stroke) * Please attach any documentation that may be helpful, such as discharge reports from hospital We will accept jpg, jpeg, png, pdf and, doc, docx files only. Select Files Cancel Any recent rehabilitation: (details of service and completion dates) Please attach any documentation that may be helpful, such as discharge reports We will accept jpg, jpeg, png, pdf and, doc, docx files only. Select Files Cancel Other medical history: Current medication: Current stroke symptoms: Right lower limb weakness Left lower limb weakness Right upper limb weakness Left upper limb weakness Changes in sensation Visual loss Changes in cognitive/thinking skills Communication difficulties Fatigue Swallowing difficulties Emotional lability Other: Level of indoor mobility: Independent Uses a walking aid (e.g. walker, stick) Assistance of one Any other details: Goals for the community stroke programme (what would you like us to work on with you?): Goals for the community stroke programme (what would you like us to work on with you?): 1 2 3 If you are a human seeing this field, please leave it empty.