Victorian Statewide Referral Form	General Practice version April 2024

REQUEST FOR EATING DISORDER SERVICE APPOINTMENT 
E-refer via ReferralNet (BH.Mental.Health)
FAX:  03 4215 2590

GP Referral

Referral Date: <<Miscellaneous:Date (short)>>
Feedback Requested:  <<Feedback requested>>

Referral to:

Barwon Health Eating Disorder Service
Dr Adam De Chellis

Phone: MHDAS TRIAGE 1300 094 187
Fax: 03 4215 2590

Referral Urgency: <<Referral Urgency>>
Referral valid for: <<Referral valid for>>

Referring General Practitioner:
Name:<<Doctor:Name>>
Practice: <<Practice/Location:Name>>
Address:<<Practice/Location:Address>>
Phone: <<Practice/Location:Phone>>  
Fax:  <<Practice/Location:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>

Patient/Client/Consumer details:
Title: <<Patient Demographics:Title>>
First name: <<Patient Demographics:First Name>>
Surname: <<Patient Demographics:Surname>>
Preferred Name: <<Patient Demographics:Known As>>
Date of Birth: <<Patient Demographics:DOB>>  Age: <<Patient Demographics:Age>>
Gender: <<Patient Demographics:Gender>>
ATSI: <<Patient Demographics:ATSI>>
Interpreter required: <<Patient Demographics:Requires Interpreter>>
Preferred language is: <<Patient Demographics:Language Spoken>>
Please consider Telehealth for this patient: <<Please consider Telehealth for this patient:>>
Cultural safety requirements: <<Cultural safety requirements?>>
Access/Support requirements: <<Access/support requirements?>>

Address: <<Patient Demographics:Address>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Email: <<Patient Demographics:E-mail>>
Home Phone:  <<Patient Demographics:Phone (Home)>>
Work Phone: <<Patient Demographics:Phone (Work)>>
Preferred method of communication: <<Patient preferred contact method>>

Medicare: <<Patient Demographics:Medicare Number>> Expiry: <<Patient Demographics:Medicare Expiry Date>>
Pension/HCC: <<Patient Demographics:Pension Number>>
DVA: <<Patient Demographics:DVA Number>>
Insurance: <<Patient Demographics:Health Insurance>>

NOK/Carer/Alternate contact:
Name: <<Patient Demographics:Next of Kin>> 
Phone: <<Patient Demographics:Next of Kin Phone>>
Relationship: <<Patient Demographics:Next of Kin Relationship>>

Consent to referral: <<Consent to referral?>> 
Consent to share information: <<Consent to share information?>>
Is this a 2nd referral for the same problem: <<Is this a 2nd referral for the same problem?>>
Usual GP (if not referrer):  <<Usual GP (if different to referrer)- Name/Practice>>

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

Reason for referral

<<Presenting complaint: (length symptoms, precipitant)>>

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

Social Hx:
 <<Clinical Details:Social History>>

Family / Supports:
<<Clinical Details:Family History>>

Other Health Professionals involved in management:
<<Other health professionals involved in management>>

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

Alerts:
<<Clinical Details:Warnings>>

Allergies: 
<<Clinical Details:Allergies/Adverse Reactions>>

Alcohol history:
<<Clinical Details:Alcohol>>

Drug Use history:
<<Drug use histroy>>

Smoking Status: <<Clinical Details:Social History>>
If smoker, smoking cessation discussed:  <<If smoker, smoking cessation discussed?>>

Physical Health Assessment <<Physical Ax: weight/height/BMI/BSL/BP/ HR>>

<<Clinical Details:Measurements (Selected)>>

Growth centile for height & weight- Children and adolescents only:  <<Growth centile for height & weight-children only>>
Weight Change in last 6 mths: <<Weight Change in last 6 mths>>
Weight Change in last 1 mth: <<Weight Change in last 1 month>>
Individual's Desired weight: <<Individual's desired weight>>

Objective clinical information: 
<<Objective clinical information>>

Investigations: 
<<Summary:Investigation Results (Selected)>>

Electronically signed: <<Doctor:Name>>

GP Referral:  <<Doctor:Name>>,  <<Miscellaneous:Date (short)>>Patient: <<Patient Demographics:Full Name>>, DOB:<<Patient Demographics:DOB>>  <<Miscellaneous:Date>> 	Page