MULTIPLE SCLEROSIS OUTPATIENT SERVICES
REFERRAL
Toronto Rehab – Rumsey Centre, 345 Rumsey Rd, Toronto, ON M4G 1R7
Phone: 416-597-3422 ext. 5319
Fax: 416-597-7160
Admission Criteria:
 Be able to actively participate in setting rehabilitation goals
 Be mentally, physically and medically stable to regularly attend and participate in therapies
 Be able to secure reliable transportation to and from outpatient appointments
 Be independently mobile, or have someone to assist them in attending appointments within the facility
 Be independent in toileting or bring attendant care
 Be able to attend therapy during work hours (9am - 4pm)
 Have an EDSS score of 2.5 – 7.0
Note: Please send all relevant consult notes and MRI/CT reports.
Incomplete referrals will not be processed and returned.
Patient's Name (Last)________________________________(First) ____________________________ Gender: M F Other
Address ___________________________________________________________________________________________________
(Street)
(Apt. #)
(City)
(Postal Code)
Ontario Health Card No. ________________________ Version Code ________
Home Telephone # __________________ Alternate Telephone # ________________ Date of Birth (m/d/y) _______________
Home Living situation:  Alone
 With Others (specify)________________________________________________________________
Currently employed:  Yes No If yes,  Full-Time  Part-Time Occupation: ___________________________________________
Primary Language spoken: ________________ Secondary Languages spoken: __________________Interpreter Needed?  Yes  No
Transportation:  Car
 TTC Wheel-Trans
 Taxi
PRIMARY CONTACT TO ARRANGE APPOINTMENTS:  Patient
SDM/POA
 Emergency Contact
Provide name and daytime telephone if different from patient
Diagnosis of MS confirmed:  Yes
 Relapsing-remitting
 NoDate of MS Diagnosis _________________________
 Primary Progressive
 Clinically Isolated Syndrome Secondary Progressive
Unknown
Please check description which best describes patient at this time:
 Category 1 – Post-exacerbation: Neurologically stable or improving
 Category 2 – Presently stable or with only slow progression of neurological symptoms
 Category 3 – Unstable – in a period of progressive neurological decline or frequent exacerbations.
EDSS Score: ______________________ (must be between 2.5 and 7.0 to be eligible for team based services)
2.5 Minimal disability in two FS (two FS grade 2, others 0 or 1) – 7.0 Unable to walk beyond approximately 5 meters even with aid, essentially
restricted to a wheelchair; wheels self in standard wheelchair and transfers alone; up and about in wheelchair some 12 hours a day
REPORTS ATTACHED: Consultation reports:  Yes MRI/CT scans: Yes OT/PT/SLP notes, etc  Yes
Documented evidence of spinal cord involvement:  Yes
 No

Other Significant Medical Conditions:
Cardio-Respiratory:Yes NoPrevious MI Heart failure
HypertensionCOPD/Asthma
Diabetes Mellitus:
Yes No
Details:______________________________________________________________
Psychiatric Disorders:
Yes No
Details:______________________________________________________________
Substance Abuse:
Yes No
Details______________________________________________________________
Seizure Disorder:
Yes No
Details:______________________________________________________________
Free of seizures for at least 6 months Yes No
Other:_____________________________________________________________________________________________________
Medications: ______________________________________________________________________________________________
Allergies (including food): ___________________________________________________________________________________
Services Requested:
Team & Physiatry:  Occupational Therapy
 Physiotherapy
Social Work
Speech-Language Pathology
 Physiatry
Physiatry Only:  Dr. Bruno (Does patient have neurologist in community Yes No, specify name: ____________________________)
Form M-0010 (DRAFT revision March 2017)
Prior Neurological Consultations: __________________________________________________________________________________________________
Hospital Admissions: Reports attached Yes 
Acute Care: _____________________________________Admission Date ________________ Discharge Date ________________
Rehabilitation: ___________________________________Admission Date ________________ Discharge Date ________________
Fatigue / activity tolerance:
Before requiring a rest, the patient can participate in daily activities for:
 Less than 30 mins
 30 mins – 1 hour
Self Care:  Independent
Continence:
 Supervision
 Yes
Bowel
 1-3 hours
 More than 3 hours
 Partial Assistance
 No
Bladder
 Yes
 Total Assistance
 No
If patient requires assistance with toileting, who will provide assistance while attending therapy?
Transfers:
 Independent
Supervision
Ambulation:  Independent
 1 person
 Supervision
 1 person
Specify ___________________________
 2 person
 2 person
 Mobility aide: specify__________________________________________________
Limbs:
 Normal
 Left side impairment
 U/E impairment
 L/E impairment
Ataxia: Check all that apply:  Unilateral
Speech / Language:
Vision:
 Intact
Cognition:
 Intact
 Intact
 Right side impairment
 Both
 Bilateral
 Impaired
 Truncal
 Bilateral impairment
 Other: _____________________
 Mild
 Moderate
 Severe
 N/A
(specify)____________________________________________________
 Impaired (specify)________________ Hearing:  intact
 impaired (specify)_________________
 Impaired If impaired, please indicate how the following functions are affected (from a cognitive perspective):
 Basic ADL’s (e.g., bathing, dressing, etc.) (specify)_________________________________________________________________________
 Community Living Skills (e.g., banking, cooking, transportation, etc.) (specify)___________________________________________________
 Safety Awareness (e.g., able to identify emergencies / risk issues) (specify) ______________________________________________________
 Return to work (specify)__________________________________________________________
Behaviour Issues:
 Yes
 N/A
No if yes, please specify _____________________________________________________________
Please identify specific goals for which rehabilitation is requested:
________________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Therapy restrictions:  Unrestricted Progressive physical activity with avoidance of ____________________________________________
Safe to participate in warm therapeutic pool (hydrotherapy) if therapist indicates this is necessary?  Yes
No
Explain:_____________________________________________________________________________________________________
REFERRING PHYSICIAN / REFERRAL SOURCE:
Name ___________________________________________
Address _________________________________________
_________________________________________________
Telephone ___________________ Fax _________________
FAMILY PHYSICIAN:
Name _______________________________________________
Address_____________________________________________
_____________________________________________
Telephone _____________________ Fax _________________
Referring Physician’s Signature ___________________ Physician’s name (print)______________________Date_________________
Billing Number_________________________
WAIVER
Patient's Name (Last)__________________________________ (First)___________________________________________________
Date of Birth (mm/dd/yyyy)__________________________________
I HEREBY AUTHORIZE ______________________________________________________________________ TO RELEASE TO
THE TORONTO REHABILITATION INSTITUTE ANY MEDICAL RECORDS OR INFORMATION CONCERNING MY
CONDITION. DATED THIS _______________ DAY OF __________________, 20____.
Patient's Signature________________________________
Form M-0010 (DRAFT revision March 2017)
Witness ___________________________________________