Referral Home » Referral Referral NDIS Hydrotherapy Must Be Completed By A Doctor Or Allied Health Specialist Client Name DOB Gender MF Address Phone Email Weight DVA Gold Card No: Expiry Date Compensation Insurer Claim No Referrer Name Phone Address Fax Reason for Referral/Goals Relevant Medical History Mobility Aid IndependentAssistance Required Weight bearing status Access pool by StairsHoist Swim Ability Can swimLow confidenceNeeds Assistance Please indicate any of the following precautions that are relevant to your client History of seizure, fainting, epilepsy (must be well managed)Unstable anginaCardiac condition/surgeryAcute infectionGastroenteritis in the last 7 daysConjunctivitis in the last 7 daysBariatricProven bromine sensitivityDiabetesRenal impairmentBlood borne virusesLines/catheter/peg/stomaRespiratory impairmentRecent DVT/PESwallow impairmentHypertensionHypotensionHydrophobiaBehaviour/cognitive impairmentIncontinence— bladderIncontinence— bowel (must be managed)Hearing impairmentVision impairmentThermoregulation impairment (ie: MS)Peripheral neuropathyHaemophilia I, the Referrer, declare that the above patient is fit for the hydrotherapy general exercise group. I declare that he/she has no obvious medical condition that will prevent him/her using a hydrotherapy pool where the temperatures are 32-34 degrees.
