SALHN High Risk Foot Service
Intake Referral Form	Ph: (08) 8204 4884
Mob: 0403 093 758
Fax: (08) 8204 5020
Email: Health.SALHNPodiatry@sa.gov.au	

SALHN HRFS Triage Information

Date Received: ....../....../......

Triaged by: ..........................Date Triaged:....../....../......
 
Site Allocation:	
	
FMC	
	
NH	
	
GMAR	

Time frame for appointment: ....................................	

	
 Category 1 (Urgent)	

	
 Category 2 (Semi Urgent)	

	
 Category 3 (Non-Urgent)	

	

MRN:................................................................................................Wait list entered: ......../........../.........

Appointment: ......../........../.........                   Time: ........................ AM  /  PM    Visit no:..........................................                
Letter / Phoned: 		/ 		/  			

Details.................................................................................................................................................................................

Patient Details:	
Date: <<Miscellaneous:Date>>
Title: <<Patient Demographics:Title>> DOB: <<Patient Demographics:DOB>> 
Name: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>> 
	GP Details: <<Practice/Location:Location Name>>
Phone: <<Patient Demographics:Phone (Mobile)>> / <<Patient Demographics:Phone (Home)>>	Gender: <<Patient Demographics:Gender>>
Aboriginal and/or Torres Strait Islander: <<Patient Demographics:ATSI>>
Is the Patient ambulant: <<Is the patient ambulant?>>
Interpreter Required: <<Is an interpreter required?>>	

Address:    <<Patient Demographics:Full Address>>

	Language: <<Patient Demographics:Language Spoken>>                          	

Inclusion Criteria, please tick appropriate:	

 High Risk Foot Service	

       (Flinders/Noarlunga Hospital & GP Plus Marion)

 Foot wound deep to tendon/joint/bone	

	
 Foot wound in the absence of pedal pulses	

	
 Foot wound not healing after 4 weeks of appropriate treatment	

	
 Known or suspected acute Charcot neuroarthropathy	

	
 Local foot infection (e.g. cellulitis/osteomyelitis)	

Please refer directly to the closest Emergency Department for:
•	Foot wound with systemic signs of illness 
            (e.g. sepsis)
•	Critical Limb Ischemia	
	
Paediatric Podiatry Service	

       (Noarlunga Hospital)

 Persistent lower limb pain, night	

             pain,  limping, or joint stiffness

Toe walking > 3 years or inability to 	

            reach plantar grade foot position

 Not walking > 18 months	

	
 Structural and/or congenital 	

             or function variance affecting gait or
             ability to participate in activity 
             expected for their age 

 Newly diagnosed neurological, 	

          rheumatology  or complex 
            orthopaedic condition with referral  
            from AH/Medical with no previous    
            podiatry intervention.	

 Ingrown Toenail Surgery  (Noarlunga Hospital)	

	
 Infected ingrown toenail	

	
 Ingrown toenail nail not responding to conservative treatment	

Note:
  Asymptomatic pes planus or asymptomatic   intoeing/outtoeing are not eligible. 	

Medical, Foot & Social History:	

Past Medical History: (relevant birth, developmental or family history for paediatric referral):
<<Clinical Details:History List>>

	
	
 Previous foot wounds 	

	
 Previous amputation	

	
 Previous Charcot neuroarthropathy	

	
Peripheral arterial disease	

	
 Loss of protective sensation	

	
 Significant foot deformity	

Foot Pathology History: (aetiology, location, duration, offloading, previous/current treatment):

Investigations: (radiology, pathology, vascular imaging):

Medications: (relevant birth, developmental or family history for paediatric referral):
<<Clinical Details:Medication List>>

Medical, Foot & Social History continued...	

Allergies: 
<<Clinical Details:Allergies/Adverse Reactions>>

Social History:
<<Clinical Details:Social History>>

Risk Factors:
<<Clinical Details:Smoking>>
<<Clinical Details:Smoking Quitting Stage>>

SINBAD Score	
Category	Definition	SINBAD Score	
Site	
Forefoot
Midfoot and hindfoot

	
0	

1	

	
Ischemia	
Pedal blood flow intact, one pulse palpable
Clinical evidence reduced pedal blood flow	
0	

1	

	
Neuropathy	
Protective sensation intact
Protective sensation lost	
0	

1	

	
Bacterial Infection	
None
Present
	
0	

1	

	
Area	
Ulcer <1cm2
Ulcer <1cm2
	
0	

1	

	
Depth	
Ulcer confined to skin and subcutaneous tissue
Ulcer reaching muscle, tendon, or deeper
	
0	

1	

	
Total Score:		
	
/ 6	

Referring Practitioner Details

Name: <<Miscellaneous:Current User>>

Signature:......................................................................

Profession: 

Contact Phone: <<Practice/Location:Phone>>

Contact Email:  <<Practice/Location:E-mail>>

Please Send completed form to either:
Fax:
08 8204 5020
Email:
Health.SALHNPodiatry@sa.gov.au