Get the free Gait Lab Referral Form - St Georges Hospital

Gait Laboratory Douglas Baker Rehabilitation Center Queen Mary's Hospital Rockhampton London SW15 5 IN Tel: 020 8487 6101 email: gait lab Georges.NHS.UK GAIT ANALYSIS REFERRAL FORM To the Referrer

How to fill out gait lab referral form

How to fill out a gait lab referral form:

1. Begin by entering your personal information, including your full name, date of birth, and contact information. This will help the gait lab identify and communicate with you during the process.
2. Next, provide details about your healthcare provider or physician who is referring you to the gait lab. Include their name, contact information, and any relevant professional or clinic details. This information is necessary for the gait lab to coordinate with your healthcare provider.
3. Indicate the reason for the referral. Specify the symptoms or conditions that have prompted your healthcare provider to recommend a gait lab evaluation. Clearly explain any concerns or issues you are experiencing, as this will assist the gait lab in understanding your needs.
4. If applicable, list any relevant medical history or pre-existing conditions that may impact your gait analysis. This includes previous surgeries, injuries, or neurological conditions. Provide accurate and comprehensive information to ensure the gait lab can make informed decisions about your assessment.
5. Outline any medications you are currently taking, including dosage and frequency. Certain medications can affect your gait and may need to be considered during the analysis. It is crucial to provide this information to the gait lab for a comprehensive evaluation.
6. Specify any assistive devices you utilize, such as orthotics, braces, crutches, or wheelchairs. These devices can influence your gait and should be accounted for during the assessment. Including this information helps the gait lab tailor their evaluation specifically to your needs.
7. If you have relevant imaging or diagnostic reports related to your condition, make sure to attach them to the referral form. This includes X-rays, MRIs, or other scans that could provide additional insights into your gait.
8. Finally, review the completed referral form to ensure all sections are filled out accurately and thoroughly. Double-check for any missing or incorrect information before submitting the form to the gait lab.

Who needs a gait lab referral form:

1. Individuals experiencing issues with their mobility or walking patterns may require a gait lab referral form. This includes those who have difficulties walking due to pain, balance problems, or muscle weakness.
2. Patients recovering from surgery or injury affecting their lower extremities may need a gait lab referral form. Gait analysis can aid in assessing the progress of rehabilitation and identifying any residual complications or imbalances.
3. Individuals with neurological conditions, such as stroke, cerebral palsy, or multiple sclerosis, might benefit from a gait lab referral form. Gait analysis can help in evaluating the impact of these conditions on walking patterns and determining appropriate interventions.
4. Athletes or sports enthusiasts seeking to optimize their performance or prevent injuries may seek a gait lab referral form. Analyzing their gait can provide valuable insights into technique, muscle imbalances, or potential areas of improvement.
5. Individuals with developmental concerns, such as children with delayed walking milestones, may require a gait lab referral form. Gait analysis can assist in identifying any underlying issues and determining appropriate interventions.

It is important to note that the specific criteria for needing a gait lab referral form may vary depending on the healthcare provider or gait lab's requirements. It is always best to consult with your healthcare provider to determine if a referral is necessary.

For pdfFiller’s FAQs

What is gait lab referral form?

The gait lab referral form is a document used to refer a patient to a gait analysis laboratory for evaluation of their walking pattern and biomechanics.

Who is required to file gait lab referral form?

Healthcare providers such as doctors, physical therapists, or orthopedic surgeons may be required to file the gait lab referral form for their patients.

How to fill out gait lab referral form?

The gait lab referral form typically requires information about the patient's medical history, current condition, and reason for referral. It may also include contact information for the referring healthcare provider.

What is the purpose of gait lab referral form?

The purpose of the gait lab referral form is to provide detailed information about the patient's condition and the reason for referral to the gait analysis laboratory.

What information must be reported on gait lab referral form?

The gait lab referral form may require information such as the patient's name, date of birth, medical history, insurance information, current medications, and the referring healthcare provider's contact information.

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