REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
A&TSI HEART HEALTH CLINIC
ABORIGINAL AND TORRES STRAIT ISLANDER (A&TSI)
EARLY INTERVENTION AND CHRONIC DISEASE MANAGEMENT SERVICES
A partnership between the Aboriginal & Torres Strait Islander Health Unit, 
Department of Cardiology and the Chronic Disease Wellness Program

SEND TO: Professor Rohan Jayasinghe
Central Intake Unit
Fax: 1300 668 536             OR Phone: 1300 668 936

Secure Transmission Service via Medical Objects or Healthlink to:
QHEALTH, GOLD COAST HEALTH Adult Community Health Central Intake Unit	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

Dear Professor Jayasinghe

SECTION 1 Patient details

RE: <PtFullName>
DOB: <PtDoB>
AGE: <PtAge>

Gender: <PtSex>
Address: <PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>
Medicare Number*: <PtMCNo> (*Medicare ineligible patients will incur a consultation fee)	Next of Kin/Alternative Contact: <NOKName>
Next of Kin/Alternative Contact Ph: <NOKContact>
Does patient identify as Aboriginal and/or Torres Strait Islander: <Does pt identify as Aboriginal/Torres Strait Islander>
Interpreter required: <Interpreter required>
If yes, specify language: <If yes, specify language>	

SECTION 2 Reason for referral and additional clinical information

Heart Health is an early intervention Cardiac Screening Clinic that includes a Cardiology consultation targeting Aboriginal and/or Torres Strait Islander community members with high cardiovascular risk.

What is the reason for this referral: <Specify main reason for referral>

Please provide provisional diagnosis (if available): <Provisional diagnosis if available>

Please include any symptoms and date of onset (if known): <Symptoms and date of onset if known>

Paste or type relevant history, clinical examination findings and treatment to date if required

SECTION 3 Mandatory clinical information

Does the patient identify as Aboriginal and/or Torres Strait Islander: <Does patient identify as Aboriginal and/or TSI>
If patients do not identify as Aboriginal and/or Torres Strait Islander they are ineligible for this service.

Smoker (current): <Smoker (current)>
Alcohol intake > recommended: <Alcohol intake > recommended>
Physically active >= 3 days a week: <Physically active >=3 days a week>
Social Isolation: <Social isolation>
Diabetes mellitus: <Diabetes mellitus>
Hypertension: <Hypertension>
Depression or other mood disorder: <Depression or other mood disorder>
Please provide details of depression or mood disorder: <Specify details of depression or mood disorders>

Clients who have a diagnosed cardiac condition are not suitable for this clinic

Is this patient known to private consultant/s: <Is this pt known to a private consultant/s>
If yes, please specify: <If yes please specify Consultant's name and details>
Has a Team Care Arrangement been completed:<Has a Team Care Arrangement been completed>
If yes, attach GPMP/TCA
Does patient have Close the Gap medication assistance: <Does the patient use Close the Gap Medication>
Can patient participate in allied-health led exercise program: <Can pt participate in allied-health exercise program>
Are there restrictions to consider during exercise:<Are there restrictions to consider during exercise>
If yes, please specify: <If yes, specify details of restrictions to consider>

SECTION 4 Investigations

Please indicate whether the following pre-requisite investigations have been undertaken in order for this referral to be processed and attach the results. In addition please also attach any investigation results you consider to be relevant.

Electrocardiogram (ECG) within last 3 months: <Electrocardiogram (ECG) within last 3 months>
FBC, lipids, E/LFT, glucose within 3 months: <Bloods within the last 3 months>

<Ix>
SECTION 5 Social factors and impact on the patient

Consider the impact on employment/education; activities of daily life; ability to care for others; personal safety/frailty; other factors. Please paste or type relevant information.

	

SECTION 6 Medical history including co-morbidities and previous surgical interventions

Alochol: <AlcHx>
Smoking: <SmkStatus> <SmkHx>
<PMHAll>
Allergies: <Reactions>
Current prescribed medications: <CurrentRx>

SMOs/VMOs in this Specialist Service

Professor Rohan Jayasinghe