Make a Referral

History and Examination

Previous Independence

Completely Independent Can Feed and Dress but need help Lives with carer Lives in Nursing Home Severe dementia Requires 24 hour care Moribund

Check if Patient is on

Aspirin Warfarin Clopidogril Other Anticoagulant

GCS

Eyes

4 - Open Spontaneously 3 - Open to Speech 2 - Open to Pain 1 - Do not Open

Voice

5 - Oriented 4 - Confused 3 - Words 2 - Sounds 1 - Nothing

Motor

6 - Obeys Commands 5 - Localises to Pain 4 - Withdraws from Pain 3 - Flexes to Pain 2 - Extends to Pain 1 - Nothing

Left Pupil Size / mm

1 2 3 4 5 6

Right Pupil Size / mm

1 2 3 4 5 6

For Spinal Referrals

Bladder Function is Abnormal Bowel Function is Abnormal There is loss of anal tone on PR Patient has Priaprism There is loss of perineal sensation