ABI Concussion Services Referral Form Referral for Concussion Services Please fill in sections 1 to 3 of this form for patients with Concussion, mTBI or moderate TBI. ABI Concussion Services Referral Form 1. Client DetailsClient name(Required) First ACC45 number(Required)National Health Index (NHI) numberDate of birth MM slash DD slash YYYY EthnicityPhone numberAddress Street Address Next of Kin details and alternative contact detailsGP detailsWas the client employed at the time of the accident? Yes No Is the client off work? Yes No Occupation if employedEmployer contact nameEmployer phone numberIs the client a student at the time of accident? Yes No Name of school2. Injury DetailsDate of referral DD slash MM slash YYYY Date of injury DD slash MM slash YYYY Is this Concussion or TBI the principal injury an additional injury? Please list all injuries listed on ACC45Briefly describe how the injury occurred, eg the mechanism of injuryBriefly describe any hospital admission, procedures, issues or complications that have occurred since injurySummary of current function and goalsSocial situation and supportWhich of the following symptoms were present at the time of assessment/examination? Please tick all that apply Loss of consciousness reported Mood changes (eg depression, anger) Loss of balance Fatigue Visual disturbances Difficulty concentrating Headaches Muscular aches Nausea Dizziness Memory problems Results and scores of any symptom reporting scales (eg Rivermead or BIST)List any other injuries or symptoms that are relevant to this referralList any pre-existing factors (e.g. comorbidities, previous TBI/concussion, mental health) that may impact recoveryProvide details of any identified risks (e.g. COVID, Long COVID, physical or verbal aggression, drugs or alcohol, dogs at home)Provide details of what rehabilitation you think the client needsAttach ACC45, discharge summary/ GP notesMax. file size: 300 MB.3. Referrer DetailsReferrer nameDisciplineHospital or GP practice nameContact phone numberEmail Date DD slash MM slash YYYY CAPTCHA
