GNEw9010 SERV0010 GNEwGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010GNEw GNEw9010 Page ]Z0*<6xxxxxxxxxxxxxxxPage number Re: ] JBO5& DOB: ] JBO5 GNEweparator 4D_enable 4D_checkableGNEw9010 Page ]Z0*<6xxxxxxxxxxxxxxxPage number Re: ] JBO5& DOB: ] JBO5 TRPweparator 4D_enable 4D_checkableTRPw0010IRPXIRPUVT$m@dXXIRPWNorth Lakes - Admin Room on LU 4dXA4'FNIwDoConfirmq@1FNIw0010 nMRPwMRPw4010/= +ee+H++HHeHHeH?XIPw XIPw301BORPweparator 4D_enable 4D_checkablePRPw1010  TNFw TNFw0010Times New RomanArial Arial NarrowSymbolLTSwNormalLTSw0010PRPw1010  TTSw1010ABATw2010Times New Roman@@@@@@h@D@ @@@@@l@H Metro North Hospital & Health Service Central Patient Intake OUTPATIENT REFERRAL FORM @H@l@@@@@ @D@h@@@@@ CPI, Aspley Community Health Centre, 776 Zillmere Road, Aspley, QLD, 4034 @@@@d@@@@@@@@h@D@ @Phone  1300 364 938 Fax:  1300 364 952 @@ @D@h@@@@@@@@d@@@  Information and resources are available at  www.health.qld.gov.au/metronorth/refer/  Please direct an acutely unwell patient to the Emergency Department @@@@@@h@D@ @@@@@l@H  Secure electronic transfer to: Metro North Central Patient Intake (MQ40290004P) @H@l@@@@@@@@d@@@============================================================================== Specialty referred to:  Location: ROYAL BRISBANE WOMENS HOSPITAL Referral date: ]zzlJBO5ZNKOT@NRTX& Show_CurrentDatew@ Length of referral:  ============================================================================== Patient Details @@@@@#@ZRe: ] JBO5&  Preferred name: @@@@#@ZDOB: ] JBO5  Age: ] JBO5%    Se x: ] JBO5 @Q@@Address: @@@@Q] JBO5 ] JBO5H ] JBO5 ] JBO5, ] JBO5+  @@Postal Address  (if different from above):  Phone (Home): ] JBO5   Phone (Work):] JBO5!   Phone (Mobile): ] JBO5J Alternate contact person: Relationship to Patient::  Alternate contact person phone number: Aboriginal or Torres Strait Islander origin: Interpreter Required: Preferred Language:   Medicare Number: ] JBO5'  DVA Number:  ] JBO5# DVA Card Type:  Occupation: Health Insurance Provider: ] JBO5: @@Workers Compensation claim: >\gB\gBCCWorkers Compensation claim details:  @@ ============================================================================== Primary Reason for Referral    Detailed history or comments: ============================================================================== Patient History Relevant Medical and Surgical History: Medication List: ]ddVJBO5DNKOT@NRTX Show_Scriptsw Allergies/ Adverse Events (including medications / food / latex / environment eg grasses): ]ffXJBO5FNKOT@NRTX Show_Allergies. Relevant Social History: Relevant Family History: Smoking Status: ]bbTJBO5BNKOT@NRTX SmokingInfo Alcohol Consumption: Do you consider the patient to be frail: Yes__ No__ @@ @D@h@@@@@@@@d@@@If yes, please provide the Clinical Frailty Score: 1 Very Fit __>GBGBCC>BBbCbC4 Vulnerable __>z@Bz@BCC7 Severely Frail __ 2 Well __ >PAPABB>BBCC>BBbCbC5 Mildly Frail __>XfBBXfBBCC8 Very Severely Frail __ 3 Managing Well __ >gBgBbCbC6 Moderately Frail __ 9 Terminally Ill __ @@ @D@h@@@@@@@@d@@@ Clinical Frailty Tool:  www.bit.ly/cfscore  What additional documents have been faxed or sent: Recent Investigations: ============================================================================== Referring Doctor Details Doctor : ] JBO5    Provider No.: ] JBO5 !   Doctor Address:  ]vvhJBO5VNKOT@NRTX" Write_HandleField   @@ @@@@M@U@7 Phone: ] JBO5   Fax: ] JBO5  @@@ @@@M@U@7 Patient s Usual G.P. (if different from referrer):  Is anyone else involved in the care of the patient?:  Verification   Signed electronically: ] JBO5  >\B\BCC !MNHHS RBWH Adult Referral v6.2 Genie 180701 ! ==============================================================================