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 (does not utilise Medicare items)

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

Secure transmission service via Medical Objects or 
Healthlink to
QHEALTH, GOLD COAST HEALTH Adult Community Health
Central Intake Unit

From Treating Doctor.Name
Practice.Name
Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Email: Treating Doctor.E-mail
Provider Number: Treating 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

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.NOK Name
Next of Kin/Alternative Contact Ph: Patient Demographics.NOK Mobile Phone
Does patient identify as Aboriginal and/or Torres Strait Islander: Does pt identify as 
Interpreter required: Interpreter required
If yes, specify language: If yes, specify lang

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: Specify reason

Please provide provisional diagnosis (if available): Provisional diag

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

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 diagnosis of Heart Failure: heart failure
If yes, please specify type known: specify heart

When was the diagnosis made: Diagnosis date

Has a Team Care Arrangement been completed: Team Care Arrangemen
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:  Bloods
A recent ECG (if available): ECG
A recent chest x/r report (if available): chest x/r

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

Clinical Details.Result List (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.Problem List (Current) With Comments

Clinical Details.Problem List (Resolved) With Comments

Allergies: Clinical Details.Allergies

Current prescribed medications: Clinical Details.Medications - Current Regular

SMOs/VMOs in this Specialist Service

Professor Rohan Jayasinghe | |

Patient Name: Patient Demographics.Full Name   DOB: Patient Demographics.DOB
Developed in partnership by General Practice Gold Coast, Gold Coast Primary Health Network and Gold Coast Health - 2019