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

Miscellaneous.Date

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.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 Demographics.DVA Expiry Date

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

SECTION 2 Reason for referral

Please select the reason for referral:  Reason for referral

Date of positive COVID PCR or RAT: PCR Date

Rapid Antigen Test visualised or at home: RAT

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

Patient vaccination status: Vacc status

Is the patient symptomatic?  Symptomatic  If yes, date of symptoms onset: Symp onset

SECTION 3 Symptoms (Adult)

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

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

*Consider if patient requires immediate transfer to hospital

SECTION 4 Medical Risk Factors (Adult)

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

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

SECTION 5 Social Risk Factors (Adult)

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

SECTION 6 Medications and Investigations

Current prescribed medications:
Clinical Details.Medications - Current Regular

eGFR results:eGFR results

eGFR results date: eGFR results date

Clinical Details.Result List (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 	
	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