Download wrha audiology referral process - Winnipeg Regional Health Authority

INTAKE
USE
ONLY
REQUIRED INFORMATION
REFERRAL DATE
AUDIOLOGY REFERRAL
a
Fax 837-5781
Phone 837-0511
REQUEST
FOR:
MALE 
FEMALE 
LAST NAME
COMMUNICATION DISORDERS - GRACE HOSPITAL
300 Booth Drive Winnipeg, Manitoba R3J 3M7
FIRST NAME
BIRTH DATE
D
M
Y
ADDRESS
AUDIOLOGY ASSESSMENT

(Include background information & previous audio results) 2ND OPINION

ABR

PARENTS
AUDITORY PROCESSING ASSESSMENT

HOME PHONE
PC
CITY
(Children must be 8 years or over. Assessments by SLP and Psychology required - Please Advise Parents)
CELL
WORK PHONE
Referral
Source
MHSC#
Address
HOSPITAL#
PHIN#
ADDITIONAL INFORMATION IF APPLICABLE
PHYSICIAN
CFS WORKER
PC
ADDRESS
Fax
Phone
FAX
PHONE
Has this client had a previous test?  Yes  No Where? ____________________________ (Client may call site directly for a follow-up appt) Date ___________________________
SERVICES FOR CHILDREN
SERVICES FOR ADULTS
REASONS FOR REFERRAL: (Check all that apply)
CHILDREN ATTENDING PUBLIC SCHOOL IN THE WPG SCHOOL DIVISION (Schools in the postal
code areas R2R R2W R2X R3A R3B R3C R3E R3G R3L R3N R3M) are eligible for audiology services through
 Sudden Onset Hearing Loss Date __________________
Child Guidance Clinic. Please check with parents and refer directly to:
 Unilateral Hearing Loss
Child Guidance Clinic - Fax: 783-6068
 Rule out retrocochlear pathology
SCHOOL CHILD ATTENDS ______________________________________________________________
 Head or ear trauma
POTENTIAL RISK FACTORS
 Ototoxic medications/monitoring
 NICU > 48 hours
 Craniofacial anomalies
 Intrauterine Growth Restriction
 Birth weight < 1500 grams
 Syndrome associated with hearing loss
 Maternal Substance Abuse
 Parental Concern
 Apgar < 4 at 5 minutes
____________________________________
 Pre-operative assessment
Date _____________________________________________
(associated with craniofacial
anomalies or growth < 10%ile)
Surgery Type ______________________________________
 Post-operative assessment
Date _____________________________________________
RISKS FOR PROGRESSIVE OR DELAYED HEARING LOSS
Surgery Type ______________________________________
 Persistent Pulmonary Hypertension of the Newborn (PPHN)
 Neurodegenerative Disorder ______________________
 Hyperbilirubinemia > 400 µmol/L OR exchange transfusion
 Hypoxic-Ischemic Encephalopathy (HIE)
 Hearing loss questioned
 Prolonged Mechanical Ventilation > 5 days
 Birth weight < 1250 grams
 ECMO or iNO or HFO or HFJ ventilation
 Intraventricular Hemorrhage (Grade III or IV)
 At risk due to noise exposure
 STORCH
 Periventricular Leukomalacia
 Family history of childhood hearing loss
 Ototoxic medications (Gentamicin pre-dose level >
 Tinnitus
 Congenital Diaphragmatic Hernia
2.5 mg/L; Lasix and gentamicin combined > 5 days,
Vancomicin pre-dose level >10 mg/L)
 Meningitis
 Audiogram required for a medical
 Syndrome associated with progressive hearing loss
______________________________________________________
CHECK OTHER CONCERNS:





Hearing Loss Questioned
Unable to follow simple directions
No response to loud sounds
Developmental Delay
Autistic or PDD Features
CLIENT WILL BE NOTIFIED BY MAIL OR PHONE
REVISED MAY 2007
CHILD HAS BEEN REFERRED FOR SPEECH 




No speech
Speech or Language Delay
Failed School screening
Visual Impairment
 To initiate a WCB or VAC (DVA) claim

Unilateral

Bilateral
 Vestibular Concerns
 Hearing aid concerns
COMMENTS
______________________________________
______________________________________
______________________________________
______________________________________
DETAILS ON REVERSE
ACCESS RIVER EAST
Audiology
975 Henderson Hwy
Winnipeg, Manitoba
R2K 4L7
DEER LODGE HEARING CENTRE
Deer Lodge Centre
2109 Portage Avenue
Winnipeg, Manitoba
R3J 0L3
HEALTH SCIENCES CENTRE
General Hospital, Audiology
Children’s Hospital, Audiology
820 Sherbrook Street
Winnipeg, Manitoba
R3A 1R9
WRHA AUDIOLOGY REFERRAL PROCESS
1.
Fax your referral (837-5781) to Audiology Central Intake at the Grace Hospital.
2.
Urgent referrals are distributed immediately. Clients are notified by telephone or by mail with
instructions on how to schedule the appointment. Please note that we are unable to schedule
appointments at Central Intake.
3.
Less urgent referrals are placed on the central wait list. Clients are notified by mail that the referral
has been placed on a wait list. Referrals are taken off the wait list in order of priority and date referred.
4.
Clients, who have previously had their hearing tested at one of the sites listed on the left, can call
directly to schedule their follow-up appointment. If they are unsure where they were seen, they can
call 837-0511 for further information.
5.
Referrals for clients who attend public school in the Winnipeg School Division are eligible for services
through Child Guidance Clinic who will provide audiology services at the school the child attends.
Please refer directly to:
Child Guidance Clinic
2nd Floor, 700 Elgin Avenue
Winnipeg, Manitoba R3E 1B2
Fax: 783-6068
6.
SEVEN OAKS HEARING CENTRE
Seven Oaks General Hospital
2300 McPhillips Street
Winnipeg, Manitoba
R2V 3M3
ST. BONIFACE GENERAL HOSPITAL
Audiology
409 Tache Avenue
Winnipeg, Manitoba
R2H 2A6
The Winnipeg School Division includes schools in the postal code areas of:
R2R R2W R2X R3A R3B R3C R3E R3G R3L R3N R3M
Referrals for clients living outside of Winnipeg can be sent directly to:
Brandon Regional Health Authority - Audiology
Unit A5 – 800 Rosser Avenue
Brandon, Manitoba R7A 6N5
Phone: 1 204 571-8366
Fax: 1 204 726-8743
Norman Regional Hearing Centre - Children
Primary Health Care Centre
111 Cook Avenue, Box 240
The Pas, Manitoba R9A 1K4
Phone: 1 204 623-9697 Fax: 1 204 627-8285
Burntwood Regional Hearing Centre
867 Thompson Drive South
Thompson, Manitoba R8N 1Z4
Phone: 1 204 677-5385
Fax: 1 204 778-1453
North Eastman Health Assoc. Inc., Audiology
Beausejour Primary Health Care Centre
P.O. Box 550, 151 First Street S.
Beausejour, Manitoba R0E 0C0
Phone: 1 204 268-7489 Fax: 1 204 268-4399
Central Regional Hearing – Adults
25 Tupper Street North
Portage La Prairie, Manitoba R1N 3K1
Phone: 1 204 239-3117
Fax: 1 204 239-3148
Parkland Regional Therapy Services - Children
Central Intake – Children’s Therapy Initiative
Dauphin Regional Health Centre
625 3rd Street S.W.
Dauphin, Manitoba R7N 1R7
Phone: 204 638-2164 Fax: 204 638-2228
Central Regional Rehab Services - Children
Box 2000 Station Main
Winkler, Manitoba R6W 1H8
Phone: 1 204 331-8833 Fax: 1 204 331-8913
Toll Free: 1 800 958-3076
South Eastman Health – Audiology
P.O. Box 2560, 365 Reimer Avenue
Steinbach, Manitoba R5G 1P1
Phone: 1 204 346-7009 Fax: 1 204 346-7023
Interlake Regional Hearing Centre
c/o Selkirk & District General Hospital
PO Box 5000, 100 Easton Drive
Selkirk, Manitoba R1A 2M2
Phone: 1 204 785-7497 Fax: 1-204-785-9113
VICTORIA HEARING CENTRE
Victoria General Hospital
2340 Pembina Hwy.
Winnipeg, Manitoba
R3T 2E8
7.
The referral source will be notified if,



Clients do not attend their scheduled appointment.
Clients decline an appointment.
We are unable to contact the client by mail or phone.
Referral forms available by mail/email (Word format) Call 837-0511