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INTERMEDIATE CARE (MAGNOLIA UNIT) REFERRAL FORM – 3 PAGE DOCUMENT
Name: ................................................................................
Ethnic origin .............................................................
Address: .............................................................................
Post Code: ...............................................................
............................................................................................
Tel: .....................................................................................
Date of Birth: ............................................................
Emergency contact: ...........................................................
Relationship: ............................................................
Address: ............................................................................
Home Tel: .................................................................
............................................................................................
Work Tel: ...................................................................
Patient’s GP: ......................................................................
Surgery: .............................................................................
Tel: ………………………………………………. .........
Has the patient consented to the referral:
Has NOK/carer been notified:
YES/NO
Referred by: ……………………………………………..
YES/NO
Team/Ward …………………………………………..…
Seen by GP on (if community referred: ……………………………………………………………………………………..
NOTE: REFERRAL WILL NOT BE CONSIDERED FOR REVIEW UNLESS ALL
AREAS ARE COMPLETED.
Inpatient Details: Admission Date ……………… Time ……………. Location/Source: ………..………………….
Reason for Admission/Referral:
…………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
Current Medical Issues/Status:
Weight:
kgs …………..
Continence:
Body Dynamics Issues? YES/NO Details: …………..…………………………………..
Bladder ………………………..
Bowel ………………………………..
Pressure Issues: YES/NO Details ……………………………………………………………………………………….
Leg Ulcers: YES/NO Details ……………………………………………………………………………………………….
MRSA Positive:
YES/NO
Details………………………………………………………………………………………..
Barrier Nursing Required: YES/NO Details …………………………………………………………………………….
Bloods/Investigations: ………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
Current Medication: …………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………….
Magnolia Unit Revised 2013
Phone: 020 8702 5690 Fax 020 8702 5691
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MSU:
Details (including date sent): …………………………………………………………….
Positive? YES/NO
X-Rays: YES/NO
Details …………………………………………………………………………………………………..
Weight-Bearing Status:
POP fitted:
YES/NO
FWB YES/NO
PWB
YES/NO
NWB
YES/NO
Details……………………………………………………………………………………………
Orthopaedic Review Date (if applicable): ………………………………………………………………………………….
Future Routine Appointments:
YES/NO Details:………………………………………………………………………
Sensory Impairments:
Vision: YES/NO Details…………………………………………………………………………………………………..
Hearing: YES/NO Details………………………………………………………………………………………………..
Past Medical History:
Neurological Pathology: ……………………………………………………………………………………………………
Cardiac: ……………………………………………………………………………………………………………………….
Cognitive: …………………………………………………………………………………………………………………….
Respiratory: ………………………………………………………………………………………………………………….
Orthopaedic: …………………………………………………………………………………………………………………
Other: ………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………….
Cognitive Assessment/Issues:
MMSE Score (to be completed if AMTS 7 or below):
Score: ……………….. (please attach a copy of MMSE)
Behavioural Issues: YES/NO Details…………………………………………………………………………………..
Social Assessment/Issues:
Environmental (home) Hazards/Issues: YES/NO Details…………………………………………………………..
Safeguarding Issues Identified:
YES/NO
Details………………………………………………………………..
Family/NOK Support: ……………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………….
Mobility/Functional Level:
Functional Assessment Sheet: Please complete and attach with referral.
Current Mobility Aid: ……………………………………………………………………………………………………..
Hoist Equipment Required: YES/NO Details ……………………………………………………………………….
Known Allergies:………………………………………………………………………………………………………..
I confirm that the above named patient is medically stable for admission to (please tick)
Magnolia (No Diagnostic facilities. Medical cover out of hours via Barndoc) Fax 020 8702 5691
Name of Referrer and Designation ...................................................................................................................
Signature: ……………………………………. Contact no: ……………………………. Date: ……………………….
Magnolia Unit Revised 2013
Phone: 020 8702 5690 Fax 020 8702 5691
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SOCIAL / HOME INFORMATION
Lives:
Alone 
With  ……………………………………………………………………………….……………………
Services: CP (Enablement)  CP (Brokerage) 
DN 
SW  Other: ………………………………….
Services Details: ……………………………………………………………………………………………………………………………...
Social support (e.g. family/neighbours): ……………………………………………………………………………………………………
House  Bungalow  Maisonette  Flat  Floor: ……… Ground Floor Set Up YES/NO
Tenure: O/O 
Council 
Private Landlord 
HA 
Warden-Controlled 
FUNCTIONAL / MOBILITY ASSESSMENT
I = Independent
Mobility
Indoors
MI – Modified Independence
A = Assistance
Previous (Subjective) Level
D = Dependent
Present (Objective) Level
Outdoors
Stairs
Steps
Transfers
Bed
Type
Chair
Type
Toilet
Commode
Personal ADL
Washing/
Technique
Dressing
Toileting
Continence
Medication
Feeding/Drinking
Domestic ADL
Meal Preparation
Eating Location
Shopping
Housework
Processing (AMTS)
Orientation
Day
Month
Year
ST Memory
Ball
Car
Man
LT Memory
Address
Tel No
DOB
Place
/10
Equipment At Home:
Completed By:
Therapist Name: ……………………………… Signature: ………………………….. Designation…………………….
Contact no: .......................................................................
Magnolia Unit Revised 2013
Date:……………………………………………………….
Phone: 020 8702 5690 Fax 020 8702 5691