Address:
69 Hospital ROAD, EMERALD, 4720

Billing:
Other Option

• Reason for referral, expectations and needs (including the problem to be assessed, degree of loss of function, pain experienced)
• Patient demographics including Medicare number, interpreter requirements and mobile phone contact number
• Patient’s mobile phone contact number and an alternative postal or contact address (if not the same as usual residence)
• Presenting symptoms/observation (including evolution and duration, severity, impact of condition)
• Physical findings
• Co morbidities (including Diabetes, cardiopulmonary, renal, obesity, (BMI) and details of any associated medical conditions which may affect the condition or its treatment
• Results of relevant investigations (pathology, radiology, histology)
• Current medications and doses, prescribed and over the counter (note any recent changes in drug therapy)
• Relevant information about the patient’s condition such as previous medical/surgical treatment (include systemic and topical medications prescribed for the condition)
• Relevant psychological and social issues including impact on:
o Employment;
o Education;
o Home;
o Activities of daily living – low/medium/high
• Alerts (including Rx [sp anticoagulants, immunosuppressive], Allergies (drug/topical preparation)
• Smoking, alcohol history, substance abuse