REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
COVID VIRTUAL WARD CLINIC

SEND TO Dr Alcorn
COVID Virtual Ward

Via Medical Objects to:
QHEALTH GOLD COAST UNIVERSITY HOSPITAL - VIRTUAL WARD
CG4215000A9

or

Email: GCHHCOV@health.qld.gov.au	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

Dear Dr Alcorn

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)
Medicare Expiry: <PtMCExpiry>
DVA Number: <PtDVANo>
DVA Expiry:

Patient email address: <PtEmail>
	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

Please select the reason for referral: <Please select the reason for referral>

Date of positive COVID PCR or RAT: <Date of positive COVID PCR or RAT>

Rapid Antigen Test: <Rapid Antigen Test visualised or at home>

No test but patient meets referral criteria - send patient to GCHHS fever clinic for testing and send referral: <No test but meets referral criteria - send to GCHHS fever clinic for testing and send referral> 

Patient vaccination status: <Patient vaccination status>

Is the patient symptomatic? <Is the patient symptomatic?>  If yes, date of symptoms onset: <If yes, date of symptoms onset>

SECTION 3 Symptoms (Adult)

MODERATE risk SYMPTOMS
<Adult: New or persistent fever >38 that does not respond to therapy>	New or persistent fever >38 that does not respond to therapy	
<Adult: Persistent/worsening productive cough>	Persistent/worsening productive cough	
<Adult: Unable to tolerate any oral intake>	Unable to tolerate any oral intake	
<Adult: Diarrhoea 4 days (new symptom)>	Diarrhoea >4 times per day (new symptom)	

HIGH risk SYMPTOMS
<Adult: Shortness of breath, especially at rest*>	Shortness of breath, especially at rest*	
<Adult: Chest pain*>	Chest pain*	
<Adult: Collapse*>	Collapse*	
<Adult: New confusion*>	New confusion*	
<Adult: Fatigue limiting simple activities of daily living*>	Fatigue limiting simple activities of daily living*	
<Adult: Dizziness>	Dizziness	
<Adult: Haemoptysis>	Haemoptysis	

*Consider if patient requires immediate transfer to hospital

SECTION 4 Medical Risk Factors(Adult)

MODERATE risk MEDICAL factors
<Adult: Age 65 years or >50 years for ATSI>	Age >65 years or >50 years for ATSI	
<Adult: Chronic lung disease>	Chronic lung disease	
<Adult: Cardiovascular disease>	Cardiovascular disease	
<Adult: Chronic kidney disease; renal dialysis>	Chronic kidney disease; renal dialysis	
<Adult: Diabetes (Type 1 or 2)>	Diabetes (Type 1 or 2)	
<Adult: Severe liver disease>	Severe liver disease	
<Adult: Significant frailty or disability>	Significant frailty or disability	
<Adult: Obesity (BMI 30 or as best Ax)>	Obesity (BMI >30 or as best Ax)	
<Adult: Active cancer>	Active cancer	
<Adult: Other immunosuppressive therapy>	Other immunosuppressive therapy	

HIGH risk MEDICAL factors
<Adult: Pregnancy >22/40>	Pregnancy >22/40  Gestation (weeks): <If pregnant, gestation (weeks)>
	
<Adult: Organ transplant on immune suppressive therapy>	Organ transplant on immune suppressive therapy	
<Adult: Immunosuppressive therapy for GVHD>	Immunosuppressive therapy for GVHD	
<Adult: Haematopoietic stem cell transplant in the last 2 years>	Haematopoietic stem cell transplant in the last 2 years	
<Adult: HIV infection with CD4 T-lymphocyte count below 200 cells per mm3>	HIV infection with CD4 T-lymphocyte count below 200 cells per mm3	
<Adult: Down Syndrome>	Down Syndrome	
<Adult: Conditions in Table 1>	Conditions in Table 1	

SECTION 5 Social Risk Factors (Adult)

HIGH risk SOCIAL factors
<Adult: Homelessness>	Homelessness	
<Adult: Concerns for/at risk of violence or neglect in the home>	Concerns for/at risk of violence or neglect in the home	
<Adult: NESB where the GP cannot access interpreter services>	NESB where the GP cannot access interpreter services	
<Adult: Major mental health concerns where patient is at risk in isolation>	Major mental health concerns where patient is at risk in isolation	
<Adult: Risk of significant alcohol or drug withdrawal>	Risk of significant alcohol or drug withdrawal	

SECTION 6 Medications and Investigations

Current prescribed medications:
<CurrentRx>

eGFR results: <eGFR results>

Date of eGFR results: <Date of eGFR results>

<Ix>

Table 1: Priority group for sotrovimab therapy if Paxlovid is contraindicated

	Patients on immunosuppressive therapy	
	Rituximab / obinutuzumab / BITE antibodies within 6 months 	
	CAR-T within 12 months	
	Alemtuzumab within 3 months	
	Prednisolone ≥ 20 mg/day (or equivalent) for > 4	
	Combination therapy with corticosteroids and 2 DMARDs	
		
	Transplantation	
	Solid organ transplantation on immunosuppression	
	Allogeneic stem cell transplant within 2 years or on immunosuppression / chronic GvHD	
	Autologous stem cell transplantation within 12 months 	
		
	Chemotherapy/malignancy	
	Acute myeloid leukaemia induction / consolidation within 3 months	
	Acute lymphoblastic leukaemia induction / consolidation / maintenance within 6 months	
	Lung cancer on active chemotherapy +/- immunotherapy within 3 months	
	Other malignancies (both haematological and solid cancer): moderate intensity chemotherapy within 2 weeks (as defined by high risk of severe neutropenia (neutrophils <0.5) for 3-5 days duration post-chemotherapy)  	
	High dose cyclophosphamide (>1 g/m2) within 6 months	
		
	Immunodeficiency disorders	
	Major antibody deficiency (i.e. CVID or XLA) with an additional COVID risk factor (age > 55, obesity (> 30kg/m2), diabetes (requiring medication), CKD (eGFR < 60 mL/min/1.73m2), heart failure) OR significant underlying bronchiectasis OR on immunosuppressive therapy	
	Combined immunodeficiency syndromes including transplanted SCID where immunoglobulin replacement is required	
	HIV with CD4 < 200 cells/mm3	
	Aplastic anaemia on active therapy