REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
RHEUMATOLOGY CLINIC
Template for correspondence about patient with
INFLAMMATORY ARTHRITIS - NEW OR SUSPECTED DIAGNOSES ONLY

SEND TO Dr Jacob Ijdo (Director of Rheumatology)
Outpatient Access and Scheduling Centre
Fax: 07 5687 4497                           OR

Secure Transmission Service via Medical Objects or Healthlink to:
QHEALTH, GOLD COAST HEALTH Outpatients
Outpatient Bookings and Referrals	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

Dear Dr Ijdo

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 Mandatory clinical information

Inflammation for >6 weeks in >1 joint: <Inflammation for >6 weeks in >1 joint>
If yes, please specify: <If yes, please specify inflammation details>
Morning joint stiffness for >30 min:<Morning joint stiffness for >30min>
Duration of symptoms <1 year: <Duration of symptoms <1 year>
MCP and/or MTP positive squeeze test: <MCP and/or MTP postive squeeze test>
Family history of inflammatory joint disease: <Family history of inflammatory joint disease>
If yes, please specify: <If yes specify history of inflammatory joint disease>
Beneficial response to NSAID: <Beneficial response to NSAID>
If yes, please specify: <If yes, specify beneficial response to NSAID>
History of psoriasis, colitis, uveitis: <History of psoriasis, colitis, uveitis>
If yes, please specify: <If yes, specify hx details>
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.

Scan results: Please instruct patient to bring relevant imaging/films to clinic
ESR/CRP: <ESR/CRP>
FBC: <FBC>
E/LFTs: <E/LFTs>
Autoimmune screen (Rheum factor and/or anti CCP): <Autoimmune screen - Rheum factor and/or anti CCP>
XR of affected joint (if applicable): <XR of affected joint (if applicable)>

<Ix>
SECTION 5 Duration of referral

Please indicate how long you would like your referral to remain valid: <Duration of referral>

Indefinite referrals do not expire until the patient has been discharged by the hospital service. When referrals expire, there is an expectation that the referring GP or another GP will review the care of the patient. If the patient still requires specialist care, the GP will then be required to submit a new referral for ongoing care. 

SECTION 6 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 7 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 Jacob Ijdo (Director) (SMO)	Dr Tracey Gerald	Dr James Gray	
Dr Julien De Jager (VMO)	Dr Jennifer Ng (SMO)	Dr Sateesh Shankaranarayana (VMO)	
Dr Shunil Sharma (VMO)	Dr Jeffery Tsai (VMO)