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Microsoft word - h3981.doc

Halton Healthcare Services

Georgetown / Milton /Oakville

Oakville-Trafalgar Memorial Hospital
327 Reynolds Street, Oakville ON L6J 3L7
Ph 905-845-2571 ext 3545 Fax 905-338-4453

Michael Lang, BSc MD FRCPC
Anna Labuda, BSc MD FRCPC
Physical Medicine & Rehabilitation
Physical Medicine & Rehabilitation
Requisition for Comprehensive Spasticity Management Clinic

Patient Name: ________________________________________
Birth date: ____________________________
(YYYY / MM / DD)

Health Card Number: __________________________________

Gender: ___ M ___ F

Address: _____________________________________________________________________________________________
Home Phone: ( )_______________________________

Work Phone: (____)___________________________
Referring Physician: ________________________________
Billing Number: _______________________________

Referring Physician Phone Number: (____)__________________

Fax: (____)__________________________

Referring Physician Address: ____________________________________________________________________________

____________________________________________________________________________
DIAGNOSIS – Please check one
Spasticity due to:
 Stroke  Traumatic Brain Injury  Spinal Cord Injury  Multiple Sclerosis  Cerebral Palsy
 Other: ___________________________________________________________________________________________
LIMBS TO BE ASSESSED - Leg:  Right  Left
Arm:  Right  Left

MEDICAL HISTORY: _________________________________________________________________________________________________
___________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________
CURRENT MEDICATIONS – List attached

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Coumadin:  Yes  No
Anti-Spasticity Medications Previously Tried:

 Baclofen
Dose: ____________________________________________________________________________________ Dose: ____________________________________________________________________________________ Dose: ____________________________________________________________________________________ Dose: ____________________________________________________________________________________ ____________________________________________________________________________________
 Other: ________________________________________________ Dose: __________________________________________________
For Office Use Only

Date Received: ________________________________________
Appointment Date/Time: _______________________________________ Forrm H3981* www.haltonhealthcare.com 04/2013

Source: http://www.haltonhealthcare.on.ca/site_Files/Content/REQUISITION.pdf

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