REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
COGNITIVE DISORDERS CLINIC
Tempate for correspondence about patients with
COGNITIVE DISORDERS

SEND TO: Dr Suba Kumar (Director)
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>
Signature: <DrName>                                        	

This service is for people 45 years and over experiencing "cognitive problems" (requiring diagnosis and treatment) characterised by, progressive cognitive decline, and/or memory impairment not in relation to personality disorders, illicit drug use, Axis I disorders, pre-existing acquired brain injury (e.g. recent TBI).

<TodaysDate>

Dear Dr Kumar

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

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 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 include the results of any formal memory tests that were conducted, such as MMSE.

CT Brain: <CT Brain>
FBC, E/LFTs, CRP: <FBC, E/LFTs, CRP>
B12 Folate: <B12 Folate>
TSH: <TSH>
Mg Phosphate Calcium: <Mg Phosphate Calcium>
MSU: <MSU>

<Ix>
SECTION 4 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 5 Medical history including co-morbidities and previous surgical interventions

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

SMOs/VMOs in this Specialist Service

Dr Suba Kumar (Director)	Dr Benjamin Chen	Dr Mohammed Khafeed	
Dr Natalie Yovenko-Lahovec