Physiotherapy Referral Form

Purpose: This form is used by healthcare professionals to refer patients to a licensed physiotherapist for further evaluation and treatment based on medical findings and functional impairments.

Patient Information

Full Name: {fullName}

Date of Birth: {dateOfBirth}

Gender: {gender}

Phone Number: {phoneNumber}

Email Address: {email}

Address: {address}

Medical Record Number: {medicalRecordNumber}

Referring Physician

Name: {physicianName}

Clinic/Hospital: {clinic}

Phone Number: {physicianPhone}

Email: {physicianEmail}

Date of Referral: {referralDate}

Diagnosis and Reason for Referral

Primary Diagnosis: {primaryDiagnosis}

ICD Code: {icdCode}

Secondary Diagnoses: {secondaryDiagnoses}

Brief Summary of Patient Condition:
{conditionSummary}

Reason for Referral:
{referralReason}

Medical History

{medicalHistory}

Current Medications

{#medications}

• {medicationName}: {dosage}, {frequency}

{/medications}

Treatment Goals

{#treatmentGoals}

• {goal}

{/treatmentGoals}

Recommended Physiotherapy Interventions

{#recommendedInterventions}

• {intervention}

{/recommendedInterventions}

{#hasPreviousPhysio}

{/hasPreviousPhysio}

{^hasPreviousPhysio}

{/hasPreviousPhysio}

Functional Limitations

{#functionalLimitations}

• {limitation}

{/functionalLimitations}

Additional Notes or Instructions

{additionalNotes}

Supporting Documents

{#documentsAttached}

• {documentName}

{/documentsAttached}

Authorization

Signature of Referring Physician: __________________________

Date: {referralDate}

This document is confidential and intended solely for the use of the individual or entity to whom it is addressed.