Download Patient Name: Patient Demographics.Full Name DOB: Patient

Patient Name: Patient Demographics.Full Name DOB: Patient Demographics.DOB
Developed in partnership by General Practice Gold Coast, Gold Coast Primary Health Network
and Gold Coast Health V1
REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
VASCULAR CLINIC
Template for correspondence about patient with
PERIPHERAL ARTERIAL DISEASE
SEND TO Dr Mark Jackson (Director of
From Treating Doctor.Name
Vascular)
Practice.Name
Bookings & Referrals Centre
Practice.Address
Fax: 07 5687 4497 OR
Phone: Practice.Phone
Secure transmission service via Medical
Fax: Practice.Fax
Objects,
Email: Treating Doctor.E-mail
Healthlink or Argus to
Provider Number: Treating Doctor.Provider
QHEALTH, GOLD COAST HEALTH
Number
Outpatients
Signature
Outpatient Bookings and Referrals
Miscellaneous.Date
Dear Dr Jackson
SECTION 1 Type of correspondence - Type of corresponden
SECTION 2 Patient details
RE: Patient Demographics.Full Name
DOB: Patient Demographics.DOB
Gender: Patient
Medicare Number*: Patient Demographics.Medicare Number
Demographics.Gender
(*Medicare ineligible patients will incur a consultation fee)
Address: Patient
Mobile Ph: Patient Demographics.Phone (Mobile)
Demographics.Address
Home Ph: Patient Demographics.Phone (Home)
SECTION 3 Reason for referral
Please select the main reason for this referral: Reason for referral
If other, please specify: If other, please spe
SECTION 4 Condition-specific criteria, including 'alarm' symptoms and signs
Ischaemic changes, threatened limb, 'diabetic foot' (1): Ischaemic changes
If yes, please specify: Specify ischaemic
Claudication <50m (1): Claudication <50m
If yes, please specify: Specify claudication
Peripheral aneurysm above the treatment threshold (1): Peripheral aneurysm
If yes, please specify: Specify aneurysm
Intermittent claudication, can walk >50m (2): Intermittent claudic
If yes, please specify: Specify intermittent
Arm ischaemia with non-critical limb (2): Arm ischaemia
If yes, please specify: Specify arm ischaemi
Asymptomatic small peripheral aneurysms (2): Asymptomatic small
If yes, please specify: Specify asymptomatic
SECTION 5 Additional clinical information about the condition
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.
Duplex USS scan results (Cat 1 case only) (Only if already done): Duplex USS
U&E FBC & Coags Homocysteine level (Only if already done): U&E FBC & Coags
Glucose (HbA1c if diabetic) (Only if already done): Glucose (HbA1c)
Lipid Profile (Only if already done): Lipid Profile
Clinical Details.Result List (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
Clinical Details.Alcohol
Smoking
Clinical Details.Smoking
Occupation
Patient Demographics.Occupation
Is the patient being care for?
Is patient being car
If yes, please provide carer's name If yes, carer's name
Other relevant social factors
(Alternative contact may be used if the patient cannot be
Alternative Contact Name
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.Problem List (Current) With Comments
Clinical Details.Problem List (Resolved) With Comments
Allergies: Clinical Details.Allergies
Current prescribed medications: Clinical Details.Medications - Current Regular
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 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.
Vascular Clinic Specialists:
Dr Mark Jackson (Director) Dr William Butcher Dr Jonathan Stewart
Dr Richard Ward-Harvey