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Download gastroenterology clinic - Gold Coast Primary Health Network
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REQUEST FOR CONSULTATION GOLD COAST HOSPITAL AND HEALTH SERVICE GASTROENTEROLOGY CLINIC Template for correspondence about patient with RECTAL BLEEDING SEND TO Dr Russell Canavan (Director of Gastroenterology) Bookings & Referrals Centre Fax: 07 5687 4497 OR Secure transmission service via Medical Objects, Healthlink or Argus to QHEALTH,GOLD COAST HEALTH Outpatients Outpatient Bookings and Referrals FROM <<Doctor:Name>> <<Practice:Name>> <<Practice:Address>> Phone: <<Practice:Phone>> Fax: <<Practice:Fax>> Email: <<Doctor:E-mail>> Provider Number: <<Doctor:Provider Number>> Signature <<Miscellaneous:Date (long)>> Dear Dr Canavan SECTION 1 Type of correspondence - <<Type of correspondence>> SECTION 2 Patient details RE: <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB>> Gender: <<Patient Demographics:Sex>> Address: <<Patient Demographics:Full Address>> Medicare Number*: <<Patient Demographics:Medicare Number>> (*Medicare ineligible patients will incur a consultation fee) Mobile Ph: <<Patient Demographics:Phone (Mobile)>> Home Ph: <<Patient Demographics:Phone (Home)>> SECTION 3 Reason for referral Please select the main reason for this referral: <<Main Reason for Referral>> If other, please specify: <<If other, please specify>> SECTION 4 Condition-specific criteria, including 'alarm' symptoms and signs Dark blood coating or mixed with stool: <<Dark blood coating or mixed with stool>> If yes, please specify: <<If yes, specify dark blood with stool details>> Weight loss >5% in previous six months: <<Recent weight loss >5% in six months>> If yes, please specify: <<If yes, please specify weight loss details>> Evidence of iron deficiency: <<Evidence of iron deficiency>> If yes, please specify: <<If yes, specify evidence of iron deficiency details>> Abdominal or rectal mass: <<Abdominal or rectal mass>> If yes, please specify: <<If yes, specify abdominal or rectal mass details>> Patient and family history of bowel cancer or inflammatory bowel disease: <<Patient and family history of bowel cancer or IBD>> If yes, please specify: <<If yes, specify history of bowel cancer or IBD>> SECTION 5 Additional clinical information about the condition Patient Name: <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB (long)>> Developed in Partnership by General Practice Gold Coast, Gold Coast Primary Health Network and Gold Coast Health V1 Please paste or type (history, clinical examination findings and treatment to date). SECTION 6 Investigations Please indicate whether the following pre-requisite investigations have been undertaken in order for this referral to be processed and attach the results. In addition please also attach any investigation results you consider to be relevant. FBC: <<FBC>> Iron studies: <<Iron studies>> <<Summary:Investigation Results (Selected)>> SECTION 7 How this problem affects the patient Consider the impact on employment/education; activities of daily life; ability to care for others; personal safety/frailty; other factors. Please paste or type relevant information. SECTION 8 Relevant social information Alcohol Smoking Occupation Is the patient being cared for? If yes, please provide carer's name Other relevant social factors <<Clinical Details:Alcohol>> <<Clinical Details:Smoking>> <<Patient Demographics:Occupation>> <<Is Patient being cared for>> <<If yes, provide Carer's Name>> Alternative Contact Name (Alternative contact may be used if the patient cannot be reached through their provided contact details) Alternative Contact Phone Interpreter Required? If yes, specify language Does Patient identify as Aboriginal and/or Torres Strait Islander? SECTION 9 Medical history including co-morbidities and previous surgical interventions <<Clinical Details:History List>> <<Operation:CoMorbidities>> <<Operation:Previous Procedures>> Allergies: <<Clinical Details:Allergies/Adverse Reactions>> Current prescribed medications: <<Clinical Details:Medication List>> The Clinical Prioritisation Criteria (CPC) and Referral Guidelines describing the medical conditions suitable for referral to GCHHS Outpatient Clinics are available at http://www.healthygc.com.au/Templates-Guidelines/GP-Referral-Guidelines.aspx The CPC and Guidelines also include information about specific conditions that should be considered 'emergency referrals' and be Patient Name: <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB (long)>> Developed in Partnership by General Practice Gold Coast, Gold Coast Primary Health Network and Gold Coast Health V1 sent directly to the Emergency Department and those that are considered 'out-of-scope' for public outpatient services. Please ensure that for any new referral sections 4 and 6 in particular are completed as incomplete referrals will not be processed. Gastroenterology Clinic Specialists: Dr Russell Canavan (Director) Dr Sneha John Dr George Ostapowicz Dr Griff Walker Dr John Edwards Dr Tariq Masood Dr Kash Sheikh Dr Nicole Walker Dr Naveed Ishaq Dr Michael Murray Dr Kevin Tang Patient Name: <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB (long)>> Developed in Partnership by General Practice Gold Coast, Gold Coast Primary Health Network and Gold Coast Health V1
