REQUEST FOR CONSULTATION
MS Queensland 
MULTIPLE SCLEROSIS FITNESS PROGRAM
MS Queensland NeuroPhysio Service
Facilitating neurological physiotherapy and exercise programs for
people with progressive neurological conditions

SEND TO:
MS Queensland NeuroAssist
Email: info@msqld.org.au           

OR Phone: 1 800 177 591

	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 who have Multiple Sclerosis or progressive neurological conditions who wish to participant in fitness based exercise. Patients with a range of disability can be accommodated.

The MS Fitness program is offered at a number of venues with a range of providers. The program's aim is to offer exercise to maintain cardiorespiratory fitness, muscle endurance, strength and flexibility. Individual assessment by a physiotherapist experienced in progressive neurological conditions is the entry point to referral to suitable exercise support. Programs are offered in a group format with access to specific groups dependent on the level of supervision required by the individual as assessed by the physiotherapist.
Please be aware that costs are associated with this program and will be discussed with the patient upon receipt of this referral.

<<Miscellaneous:Date (long)>>

Dear MS Queensland Physiotherapist

SECTION 1 Patient details

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

Gender: <<Patient Demographics:Sex>>	Medicare Number*: <<Patient Demographics:Medicare Number>> (*Medicare ineligible patients will incur a consultation fee)	
Address: <<Patient Demographics:Full Address>>

Next of kin: <<Next of kin>>
Next of kin Ph: <<Next of kin phone number>>	Mobile Ph: <<Patient Demographics:Phone (Mobile)>>
Home Ph: <<Patient Demographics:Phone (Home)>>	

SECTION 2 Provisional diagnosis	

Please specify: <<Specify provisional diagnosis>>

SECTION 3 Reason for referral and additional clinical information	

Main reason for this referral or relevant history, clinical examination findings and treatment to date:

<<Specify main reason for referral/relevant history>>

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

SECTION 4 Mandatory clinical information

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

Please note that it is not a requirement of the program for a TCA to be completed.

Is the patient newly diagnosed:  <<Is the patient newly diagnosed>>
If no, please specify: <<If no, specify date>>

Does the patient have comorbidities restricting exercise: <<Does pt have comorbidities that restrict exercises>>
If yes, specify: <<If yes, specify comorbidities>>

SECTION 5 Investigations

Please attach any investigation results you consider to be relevant.

<<Summary:Investigation Results (Selected)>>

SECTION 6 How this problem affects 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 Relevant social information

Alcohol	<<Clinical Details:Alcohol>>	
Smoking	<<Clinical Details:Smoking>>	
Occupation	<<Patient Demographics:Occupation>>	
Is the patient being cared for?	<<Is Patient being cared for>>	
If yes, please provide carer's name	<<If yes, provide Carer's Name>>	
Other relevant social factors	
	
Alternative Contact Name	(Alternative contact may be used if the patient cannot be reached through their provided contact details)
	
Alternative Contact Phone		
Interpreter Required? 		
If yes, specify language		
Does Patient identify as Aboriginal and/or Torres Strait Islander?		

SECTION 8 Medical history including co-morbidities and previous surgical interventions

<<Clinical Details:History List>>

<<Operation:CoMorbidities>>

<<Operation:Previous Procedures>>

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

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

SECTION 9 Information about this specialist service or condition for patients and referring clinicians

Please ensure that for any new referral section 2 through 5 in particular is completed as incomplete referrals will not be processed.

MS Queensland NeuroPhysio Service