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

<<Miscellaneous:Date (long)>>

Dear Dr Alcorn

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)
Medicare Expiry: <<Patient Demographics:Medicare Expiry Date>>
DVA Number: <<Patient Demographics:DVA Number>>
DVA Expiry: 

Patient email address: <<Patient Demographics:E-mail>>
	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

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: <<No test but meets referral criteria - test & refer*>>  - *If yes, send patient 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
<<New/persistent fever >38 not responding to therapy>>	New or persistent fever >38 not responding 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 for ATSI>>	Age >65 years or >50 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 supp therapy >>	Organ transplant on immune suppressive therapy 	
<<Adult: Immunosuppressive therapy for GVHD>>	Immunosuppressive therapy for GVHD	
<<Adult: Haematopoietic stem cell transplant last 2yrs>>	Haematopoietic stem cell transplant in the last 2 years 	
<<Adult: HIV infection + CD4 T-lymphocyte count <2>>	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
<<Homelessness>>	Homelessness	
<<Concern for/at risk of violence or neglect at home>>	Concerns for/at risk of violence or neglect in the home	
<<NESB where GP cannot access interpreter service>>	NESB where GP cannot access interpreter services	
<<Major MH concerns where patient is at risk in iso>>	Major mental health concerns where patient is at risk in isolation	
<<Risk of significant alcohol or drug withdrawal>>	Risk of significant alcohol or drug withdrawal	

SECTION 6 Medications and Investigations

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

eGFR results: <<eGFR results>>

eGFR results date: <<eGFR results date>>
<<Summary:Investigation Results (Selected)>>

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 weeks	
	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