THE SPASTIC CHILDREN’S ASSOCIATION OF SINGAPORE

Cerebral Palsy Centre, 65 Pasir Ris Drive 1 Singapore 519529Tel: 6585-5600 Fax: 6585-5603

E-mail:spastic@pacific.net.sg Website: www.spastic.org.sg

REFERRAL FORM

Client’s Full Name : _____________________________ Date of Birth: _______________________

BC/IC No: _____________________________________ Sex/ Race: __________________________

Address : _________________________________________________________________________

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Phone : ___________________________(H) Email : ____________________________

Father’s Name: _________________________________ Date of Birth : _______________________

IC/ Passport No:_________________________________ Occupation: ________________________

Contact No: _________________________ (HP) _________________________________(O)

Mother’s Name : _________________________________ Date of Birth : ______________________

IC/ Passport No: _________________________________Occupation : ________________________

Contact No: _________________________ (HP) _________________________________(O)

Any other relevant information about the client of his/her family: ______________________________________________________________________________________

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Signature : ________________________________ Name : ____________________________________

Designation : __________________________________________

Dept / Agency : _______________________________________

Date : __________________________________________

MEDICAL REPORT

Diagnosis : ______________________________________________________________

Type of Cerebral Palsy (CP) : ________________________________________________________

Other Associated Defect(s): _________________________________________________________

Current Medical Problem(s) : _________________________________________________________

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Birth History : Full Term / Prematurity / Breech / Caesarean Delivery / Others : ________________

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Neonatal History : Normal / Feeble / Blue at Birth / Convulsions / Jaundice / Others : _____________

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Family History of C.P. (If any) : _______________________________________________________

Past Illness (if any) : ________________________________________________________________

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Drug Allergy (if any) : ______________________________________________________________

Development Milestones: ____________________________________________________________

Reason(s) for referral: _______________________________________________________________

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______________________________________Name & Designation of Referring Doctor

_____________________________ Signature of Referring Doctor

______________________________________ Clinic / Department / Hospital

_____________________________ Date