REQUEST FOR EATING DISORDER SERVICE APPOINTMENT 
E-refer via ReferralNet (BH.Mental.Health)
FAX:  03 4215 2590
										
GP Referral
		Referral Date: Miscellaneous.Date
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:Treating Doctor.Name
Practice: Practice.Name
Address:Practice.Address
Phone:  Practice.Phone
Fax:  Practice.Fax
Email: Treating Doctor.E-mail
Provider No.: Treating 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.Popular Name

Date of Birth: Patient Demographics.DOB          Age: Patient Demographics.Age
Gender: Patient Demographics.Gender 

ATSI: Patient Demographics.ATSI Status
Interpreter required: Interpreter
Preferred language is: Preferred language
Please consider Telehealth for this patient: Telehealth 
Cultural safety requirements: Cultural Safety
Access/Support requirements: Access/Support		Address: Patient Demographics.Full 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: Preferred contact 

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 Fund NamePatient Demographics.Health Fund Member Number

NOK/Carer/Alternate contact:
Name: Patient Demographics.NOK Name  
Phone: Patient Demographics.NOK Mobile Phone
Relationship: Patient Demographics.NOK Relationship

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

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways	

Reason for referral:
Reason for referral

Past Medical History: 
Clinical Details.Past History

Social Hx:
Clinical Details.Social History

Family / Supports:
Clinical Details.Family History

Other Health Professionals involved in management:
Other management

Current Medication:
Clinical Details.Medications - Current Regular

Alerts:
Clinical Details.Warnings

Allergies:
Clinical Details.Allergies

Alcohol history:
Clinical Details.Alcohol

Drug use history:
Drug use history

Smoking Status: Clinical Details.Smoking
If smoker, smoking cessation discussed:  Smoking cessation

Physical Health Assessment: Physical Ax

Height: Current Measurements.Physical - Height	BP  sitting: Current Measurements.Physical - Systolic BP (Sitting)/ Current Measurements.Physical - Diastolic BP (Sitting)	
Weight: Current Measurements.Physical - Weight	BP standing: Current Measurements.Physical - Systolic BP (Standing) / Current Measurements.Physical - Diastolic BP (Standing)	
BMI: Current Measurements.Physical - Body Mass Index	Heart rate: Current Measurements.Physical - Pulse	
Temp: Current Measurements.Physical - Temperature	BSL: Current Measurements.Pathology - Blood Sugar Level	

Growth centile for height & weight- Children and adolescents only: Growth centile-child
Weight Change in last 6 mths: Weight change- 6mnth
Weight Change in last 1 mth: Weight change-1mnth
Individual's Desired weight: Desired weight

Objective clinical information: 
Objective info

Investigations: 
Clinical Details.Result List (Selected)

Electronically signed: Treating Doctor.Name