GNEw9010B  SERV0010 GNEwGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010GNEwH><\GNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010TRPweparator 4D_enable 4D_checkableTRPw0010IRPXIRPUVT$m@dXXIRPWNorth Lakes - Admin Room on LU 4dXA4'FNIwDoConfirmq@1FNIw0010 MRPwMRPw4010/= +ee+H++HHHHHHH?XIPw XIPw301BORPweparator 4D_enable 4D_checkablePRPw1010TNFw hTNFw0010Times New RomanArial Arial NarrowSymbolCalibriCambriaTimes New Roman CETimes New Roman CyrTimes New Roman GreekTimes New Roman TurTimes New Roman (Hebrew)Times New Roman (Arabic)Times New Roman BalticTimes New Roman (Vietnamese) Calibri CE Calibri Cyr Calibri Greek Calibri TurCalibri BalticCalibri (Vietnamese) Cambria CE Cambria Cyr Cambria Greek Cambria TurCambria BalticCambria (Vietnamese)Arial Narrow CEArial Narrow CyrArial Narrow GreekArial Narrow TurArial Narrow BalticLTSwNormalLTSw0010PRPw1010  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: THE PRINCE CHARLES 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: >أnCأnCCCPreferred Language:   Medicare Number: ] JBO5'  DVA Number:  ] JBO5# DVA Card Type:  Occupation: Health Insurance Provider: ] JBO5: @@Workers Compensation claim: >BBCCWorkers Compensation claim details:  @@ ============================================================================== Primary Reason for Referral    Detailed history or comments: @@ @D@h@@@@@@@@d@@@Please explain if you consider this referral urgent:  @@ @D@h@@@@@@@@d@@@ ============================================================================== 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 __>У@У@BB>BBCC4 Vulnerable __>PBPBCC7 Severely Frail __ 2 Well __ >AABB>BBCC5 Mildly Frail __>dfBdfBCC8 Very Severely Frail __ 3 Managing Well __ >p^Ap^ACC6 Moderately Frail __ >pApACC9 Terminally Ill __ @@ @D@h@@@@@@@@d@@@ Clinical Frailty Tool:  www.bit.ly/cfscore  What additional documents have been faxed: 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  > C CCC !MNHHS TPCH Adult Referral v6.2 Genie 180701 ! ==============================================================================