REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
HEART FAILURE SERVICE CLINIC
CHRONIC DISEASE WELLNESS PROGRAM
Specialising in multidisciplinary care for the patients with complex care needs; assisting clients with cardiovascular disease return to optimal health and an active lifestyle aimed at reducing the risk of further cardiac events.
Supporting Team Care Arrangements (without utilising Medicare items) 

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 <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

This service is for patients/clients 18 years and older who have a diagnosis of heart failure confirmed by a cardiologist. Heart failure diagnoses may include: Systolic dysfunction, diastolic heart failure, right heart failure.

Please refer patients who have not been assessed by a Cardiologist to either private Cardiologists where available or to Cardiology Specialist Outpatients Department using the template available on www.healthygc.com.au

<<Miscellaneous:Date (long)>>

Dear Professor Jayasinghe

SECTION 1 Patient details

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
AGE: <<Patient Demographics:Age>>

Gender: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Full Address>>
Home Ph: <<Patient Demographics:Phone (Home)>>
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>
Medicare Number*: <<Patient Demographics:Medicare Number>> (*Medicare ineligible patients will incur a consultation fee)
	Next of Kin/Alternative Contact: <<Patient Demographics:Next of Kin>>
Next of Kin/Alternative Contact Ph: <<Patient Demographics:Next of Kin Phone>>
Does Patient identify as Aboriginal and/or Torres Strait 
Islander: <<Patient Demographics:ATSI>>
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

Does this patient have a confirmed diagnoses of Heart Failure: <<Does pt have confirmed diagnoses of Heart Failure>>
If yes, please specify type known: <<If yes, specify heart failure diagnoses details>>

When was the diagnosis made: <<Specify date of diagnosis >>

Has a Team Care Arrangement been completed: <<Has a Team Care Arrangement been competed>>
If yes, attach GPMP/TCA 

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.

FBC, lipids, E/LFT, glucose within 3 months: <<FBC, lipids, E/LFT, glucose within last 3 months>>
A recent ECG (if available): <<A recent ECG (if available)>>
A recent chest x/r report (if available): <<A recent chest x/r report (if available)>>

In addition please also attach investigation results you consider to be relevant, including coronary angiography, myocardial perfusion scan, echocardiography and/or exercise stress test results

<<Summary:Investigation Results (Selected)>>

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

Alcohol: <<Clinical Details:Alcohol>>
Smoking: <<Clinical Details:Smoking>>

<<Clinical Details:History List>>

<<Operation:CoMorbidities>>

<<Operation:Previous Procedures>>

Allergies: <<Clinical Details:Allergies/Adverse Reactions>>

Current prescribed medications: <<Clinical Details:Medication List>>

SMOs/VMOs in this Specialist Service	

Professor Rohan Jayasinghe