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: Miscellaneous.Date	GP Details: Treating Doctor.Full Details	Gender Identity: 	
Title: Patient Demographics.Title	DOB: Patient Demographics.DOB	Phone: Patient Demographics.Phone (Mobile)	Aboriginal and/or Torres Strait Islander: Patient Demographics.ATSI Status	
Last Name: Patient Demographics.Surname	First Name: Patient Demographics.First Name	Is the patient ambulant: Is the patient ambul	
	Interpreter required: Interpreter	
Address: Patient Demographics.Address	Language: 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 excepted for their age.
 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) 
 Infected ingrown toenail
 Ingrown toenail nail not responding to conservative treatment		

Medical, Foot & Social History 	
Past Medical History (relevant birth, developmental or family history for paediatric referral):
Clinical Details.Family History

Clinical Details.History List

Clinical Details.Past History	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):
 Foot Pathology Histo
	
Investigations (radiology, pathology, vascular imaging)
Clinical Details.Result List (Selected)

Medications
Clinical Details.Medication List	

Medical, Foot & Social History continued...	
Allergies: Clinical Details.Allergies Clinical Details.Allergies With Comments	
Social history (working status, living arrangement, pension status, smoking status, formal supports e.g. NDIS, aged care package): Clinical Details.Social History	
Risk factors: Risk factors	

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

Referring Practitioner Details	
Name: Treating Doctor.Name
Signature:         
Profession: Treating Doctor.Qualifications
Treating Doctor.Provider Number
Contact phone: Practice.Phone
Contact email: Treating Doctor.E-mail	Please send completed form to either:
Fax
08 8204 5020

Email
Health.SALHNPodiatry@sa.gov.au