Victorian Statewide Referral Form	General Practice version Jul 2019

REQUEST FOR ORTHOPAEDIC OUTPATIENT APPOINTMENT - FAX 03 4215 1383 OR
								  - E-REFER USING REFERRAL NET

GP Referral

Referral Date:  <<Miscellaneous:Date (long)>>

Feedback Requested:  Yes

Referral to: 
Barwon Health Orthopaedics

Service requested: <<Orthopaedics>>
Urgency: <<Urgency>> 

Referral valid for:  <<Referral valid for>>

Referring General Practitioner:
<<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
HPI-0:  <<Practice:HPI-O>>
Phone: <<Practice:Phone>>   Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>
HPI-I:  <<Doctor:HPI-I>>

 ---------------------------------------------------------------------------------------------------------------------------------

Consumer details:
Name:                     <<Patient Demographics:First Name>> <<Patient Demographics:Surname>> 
Date of Birth:          <<Patient Demographics:DOB>>	Age:                        <<Patient Demographics:Age>>  Preferred Name/s:	<<Patient Demographics:Greeting>>
Sex:	<<Patient Demographics:Sex>>
Title:	<<Patient Demographics:Title>>
Pt IHI:                      <<Patient Demographics:IHI>>

ATSI:  <<Patient Demographics:ATSI>>

Contact Address:	<<Patient Demographics:Full Name>>
                               <<Patient Demographics:Address>>	
                               <<Patient Demographics:City>>	<<Patient Demographics:State>>   <<Patient Demographics:Postcode>>  
Phone:	<<Patient Demographics:Phone (Home)>>
Work:	<<Patient Demographics:Phone (Work)>>
Mobile:	<<Patient Demographics:Phone (Mobile)>>
Email:	<<Patient Demographics:E-mail>>
Alternative Contact:

Interpreter Required:  <<Interpreter required>> | Medicare Number:  <<Patient Demographics:Medicare Number>>
Preferred language:  <<Patient Demographics:Language Preferred>> | Insurance:  <<Patient Demographics:Health Insurance>>
Pension Card:  <<Patient Demographics:Pension Number>> | DVA:  <<Patient Demographics:DVA Number>>
TAC or Workcover:  <<TAC or Workcover?>> |

Date patient consented to referral:  <<Miscellaneous:Date (short)>>
Consent to share information:  <<Consent to share information>>
Consent to MBS bulk billing clinic if available:   <<Consent to MBS bulk billing clinic>>

HealthPathways provides guidance in patient assessment, management and referral.  <<HealthPathways for guidance in Mx Ax referral>>

Patient Name: <<Patient Demographics:Surname>>, <<Patient Demographics:First Name>>  DOB:  <<Patient Demographics:DOB>>

Consider using Telehealth for this patient:  <<Consider Telehealth for this patient>>

Reason for patient referral: <<Reason for referral>>

Functional Assessment:

Housebound or wheelchair bound  <<Housebound or wheelchair bound>> | | Limited walking distance < 100 m  <<Walking distance < 100m>>
Troublesome nocturnal pain  <<Troublesome nocturnal pain>> | | Unresponsive to maximal medical rx / analgesia  <<Unrepsonsive to maximal medical rx / analgesia>>
Very irritable joint  <<Joint very irritable>> | | Severe pain with ADL  <<Severe pain with ADL>>
Requires assistance with ADLs <<Requires assistance with ADLs?>> | | Falls <<Falls?>>
Patient off work due to current problem:  <<Patient off work due to current problem>> | | Pt is primary carer for relative <<Pt is primary carer for relative>>
Exercise program <<Exercise program?>> | | <<Tick any of the following exercise regime that apply>>
Exercise program provided by GP <<Exercise program provided by GP?>> | | Referred to physio for exercises  <<Referred to physio for exercises?>>
Pt does own exercises at home <<Pt does own exercises at home?>> | | Pt attends group exercise classes <<Pt attends group exercise classes?>>
Pt attends private gym  <<Pt attends private gym?>> | | Physiotherapy  <<Physiotherapy tried and response>>
Hydrotherapy  <<Hydrotherapy tried and response>> | | Podiatry/Orthotics    <<Podiatry / Orthotics tried and response>>
Weight loss program  <<Pt is on weight loss program?>> | | GP Management plan  <<GP Management plan>>
GP Team Care arrangement  <<Team care arrangement>> | |

Warnings: <<Clinical Details:Warnings>>
Allergies: <<Clinical Details:Allergies>> 
Social History: <<Clinical Details:Social History>>  <<Clinical Details:Smoking>> 
If yes to smoking, has cessation program been discussed?:  <<Smoking cessatin program discussed?>>

Current Medication:
<<Clinical Details:Medication List>>

Past Medical History: 
<<Clinical Details:History List>>

Progress Notes: 
<<Summary:Progress Notes (Selected)>>

Patient Name: <<Patient Demographics:Surname>>, <<Patient Demographics:First Name>>  DOB:  <<Patient Demographics:DOB>>

Radiographic imaging provider: <<Radiographic imaging provider>>

Investigation Results:
Please attach relevant pathology / imaging results to assist triage process. Referrals without relevant results may not be triaged and will be returned to the referrer.

Please send original XR films with patient.
<<Summary:Investigation Results (Selected)>>

GP Referral:  <<Doctor:Name>>,  Patient: <<Patient Demographics:Full Name>>,  <<Miscellaneous:Date>> 	Page