SALHN HRFS Triage Information	
Date Received:
Triaged by:                                                              Date triaged:
Site Allocation:
Timeframe 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: <TodaysDate>	GP Details: <DrDetails>	Gender Identity: <Gender Identity>	
Title: <PtTitle>	DOB: <PtDoB>	Phone: <PtPhoneMob>	Aboriginal and/or Torres Strait Islander: <Aboriginal and/or Torres Strait Islander>	
Last Name: <PtSurname>	First Name: <PtFirstName>	Is the patient ambulant: <Is the patient ambulant:>	
	Interpreter required: <Interpreter required>	
Address: <PtAddress>	Language: <Language spoken>	

Inclusion Criteria, please tick appropriate	
High Risk Foot Service <High Risk Foot Service>
(Flinders / Noarlunga Hospital & GP Plus Marion)
<Foot wound deep to tendon/joint/bone> Foot wound deep to tendon/joint/bone.
<Foot wound in the absence of pedal pulses> Foot wound in the absence of pedal pulses.
<Foot wound not healing after 4 weeks of appropriate treatment> Foot wound not healing after 4 weeks of appropriate treatment.
<Known or suspected acute Charcot neuroarthropathy.> Known or suspected acute Charcot neuroarthropathy.
<Local foot infection (e.g. cellulitis/osteomyelitis)>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 <Paediatric Podiatry Service>
(Noarlunga Hospital)
<Persistent lower limb pain, night pain, limping, or joint stiffness> Persistent lower limb pain, night pain, limping, or joint stiffness.
<Toe walking > 3 years or inability to reach plantar grade foot position.> Toe walking > 3 years or inability to reach plantar grade foot position.
<Not walking > 18 months.> Not walking > 18 months.
<Structural and/or congenital or function variance affecting gait or ability to participate in activity excepted for their age.> Structural and/or congenital or function variance affecting gait or ability to participate in activity excepted for their age.
<Newly diagnosed neurological, rheumatology or complex orthopaedic condition with referral from AH/Medical with no previous podiatry intervention.> Newly diagnosed neurological, rheumatology or complex orthopaedic condition with referral from AH/Medical with no previous podiatry intervention. 
NOTE:
Asymptomatic pes planus or asymptomatic intoeing/outtoeing are not eligible. 	
Ingrown Toenail Surgery (Noarlunga Hospital) <Ingrown Toenail Surgery (Noarlunga Hospital)>
<Infected ingrown toenail> Infected ingrown toenail
<Ingrown toenail nail not responding to conservative treatment> Ingrown toenail nail not responding to conservative treatment		

Medical, Foot & Social History 	
Past Medical History (relevant birth, developmental or family history for paediatric referral):
<SelectedPMH>
<FamilyHx>	Previous foot wounds <Previous foot wounds>
Previous amputation <Previous amputation>
Previous Charcot neuroarthropathy <Previous Charcot neuroarthropathy>
Peripheral arterial disease <Peripheral arterial disease>
Loss of protective sensation <Loss of protective sensation>
Significant foot deformity <Significant foot deformity>	

Foot Pathology History (aetiology, location, duration, offloading, previous/current treatment):
<Foot Pathology History (aetiology, location, duration, offloading, previous/current treatment)>
	
Investiagations (radiology, pathology, vascular imaging)
<Ix>	
Medications
<SelectedRx>	

Medical, Foot & Social History continued...	
Allergies: <Reactions>	
Social history (working status, living arrangement, pension status, smoking status, formal supports e.g. NDIS, aged care package): <SocialHx>	
Risk factors: <Risk factors>	

SINBAD Score	
Category	Definition	SINBAD Score	
Site	Forefoot
Midfoot and hindfoot	<SINBAD Score - Site>	
Ischemia	Pedal blood flow intact, one pulse palpable
Clinical evidence reduced pedal blood flow	<SINBAD Score - Ischemia>	
Neuropathy	Protective sensation intact
Protective sensation lost	<SINBAD Score - Neuropathy>	
Bacterial Infection	None
Present	<SINBAD Score - Bacterial Infection>	
Area	Ulcer <1cm2
Ulcer>1cm2	<SINBAD Score - Area>	
Depth	Ulcer confined to skin and subcutaneous tissue
Ulcer reaching muscle, tendon or deeper	<SINAB Score - Depth>
	
Total Score		 <Total score (out of 6)>/6	

Referring Practitioner Details	
Name: <DrName>
Signature:         
Profession: <DrQualifications>
Contact phone: <LocationPhone>
Contact email: <LocationEmail>	Please send completed form to either:
Fax
08 8204 5020

Email
Health.SALHNPodiatry@sa.gov.au