REQUEST FOR PALLIATIVE CARE SERVICE
E-refer via ReferralNet (BH.PalliativeCare)
FAX:  03 4215 6390

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

Referral to:
Barwon Health Palliative Care Service

Phone: 03 4215 5700 
Fax: 03 4215 6390

Referral Urgency: <<Referral Urgency>>
		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>>

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?>>
Consent to contact from service: <<Consent to contact from service?>>
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:
<<Reason for referral>>

Primary diagnosis:  <<Primary Diagnosis>>
Metastases, if any:  <<Metastases, if any>>
Current/Regular treatment: <<Current/Regular treatment>>
Other services involved in care:  <<Other services involved in care>>

<<Symptoms (see below)>>
Pain? <<Pain?>>
Nausea?  <<Nausea?>>
Constipation?  <<Constipation?>>
Anxiety?  <<Anxiety?>>
Depression?  <<Depression?>>
Anorexia/Weight loss?   <<Anorexia/Weight loss?>>
Shortness of breath?  <<Shortness of breath?>>
Psychosocial concerns?  <<Psychosocial concerns?>>
Comments:  <<Comments>>

Does patient have ACP/Documented Goals of Care? <<ACP/Documented Goals of Care in place?>>
Other specialists involved? <<Specialists involved in management>>
Recent PHx Medication list review undertaken:  <<Recent PHx Medication list review undertaken?>>
GP available for home visits? <<GP available for home visits?>>	

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

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

Family History:
<<Clinical Details:Family History>>

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

Alerts:
<<Clinical Details:Warnings>>

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

Alcohol History:
<<Clinical Details:Alcohol>>

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

Smoking Status:
<<Clinical Details:Smoking>>

If smoker, smoking cessation discussed: 
<<If smoker, smoking cessation discussed?>>

Electronically signed: <<Doctor:Name>>