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Aged Care & Community Services Referral Form

Patient Label

Date: Miscellaneous.Date

Service Requested: Relevant service (Please phone to discuss urgent referrals.)

Consent Is the patient agreeable to this referral? Pt Agreeable Is the carer agreeable to this referral? Carer agreeable

Patient Details Surname: Patient Demographics.Surname Given Name: Patient Demographics.First Name Date of Birth: Patient Demographics.DOB Address: Patient Demographics.Full Address Mobile phone: Patient Demographics.Phone (Mobile) Home phone: Patient Demographics.Phone (Home) Interpreter Required: Interpreter Required Language: Language spoken Medicare No: Patient Demographics.Medicare Number Pension No: Patient Demographics.Pension Number

Contact person for this referral Name: Contact person Relationship to patient: Relationship to Pt Mobile phone: Contact Mobile Home phone: Contact Home phone

GP Details Name: Treating Doctor.Name Practice Name: Practice.Name Practice Address: Treating Doctor.Address , Treating Doctor.Suburb Post Code: Treating Doctor.Postcode Phone: Practice.Phone Fax: Practice.Fax Email: Treating Doctor.E-mail

Current Functional Status:

Cognition Cognitition Other – please specify: Cognition Other

Continence Continence Continent / Incontinent - bladder / Incontinent – bowel

Communication Communication

Mobility Mobility

Self-Care Self Care

Living Arrangements/Accommodation:

Carer Availability Carer Availability

Living Arrangement Living Arrangement

Accommodation Accommodation

Safety Issues (behaviour, aggression, house, manual handling, alcohol, drugs, firearms) Safety Issues

Reason for Referral and Current Medical Problems:

(Include relevant diagnoses, duration of symptoms and mental state): Reason for Referral Mental state: Mental State Urgency: Please call the relevant service if this referral is urgent.

Past Medical History: Clinical Details.Past History

Current Medications and Dosage: Clinical Details.Medications - Current Regular

Relevant investigations and results: (Please attach copies) Clinical Details.Result List (Selected)

Other services / hospitals involved in patient’s care: Other services