Title: Central Queensland Hospital & Health Service (CQHHS) Rockhampton

CQHHS SOPD REFERRAL FORM - Gladstone Hospital
Central Queensland Hospital & Health Service (CQHHS)  
Secure electronic transfer for CQ Referral Centre
Medical Objects: (GC468000091)
HealthLink: (qldglare)
Or, fax to the CQ Referral Centre: (1300 017 155)

The above fax number cannot be used for Emergency Department or Mental Health Alcohol and Other Drugs Services
For CQ condition-specific referral criteria, visit CQ HealthPathways
Referral information
* Re:<<Patient Demographics:Title>> <<Patient Demographics:First Name>> <<Patient Demographics:Surname>> | * DOB: <<Patient Demographics:DOB>>
Referring GP: | <<Doctor:Name>>
GP phone number: | <<Practice:Phone>>
Reason for service request: | <<Reason for service request>>
Service requested: | <<Service requested>>
Referral date: | <<Referral date>>
Service provider - Gladstone: | <<Service provider - Gladstone>>
Service provider - Biloela: | <<Service provider - Biloela>>
Service provider - Rockhampton: | <<Service provider - Rockhampton>>
Priority: | <<Priority>>
Referral letter
<<Referral Letter - please detail reason for referral>>
Consents
Date patient consent to referral: | <<Does patient consent to referral?>>
Patient is willing to have surgery if required: | <<Patient is willing to have surgery (if required)>>
Are you the patient's usual GP? | <<Are you the patient's usual GP?>>
If no, patient's usual GP: | <<If not, please provide patients usual GP or Practice>>
Condition / Specialty specific clinical information - CQ HealthPathways
History and examination
Medication list: |
<<Clinical Details:Medication List>>
Investigations relevant to this referral - results <3months old at time of referral
<<Summary:Investigation Results (Selected)>>
Imaging and reports
How have medical images been transferred for review? | <<How have images been transfered?>>
Standard clinical information
Allergies / adverse reactions
<<Clinical Details:Allergies/Adverse Reactions>>
Immunisations
<<Clinical Details:Immunisation List>>
Observations
BMI: | <<Clinical Details:Measurements>>
Blood Pressure (sitting): | <<Clinical Details:Measurements>>
Blood Sugar Level: | <<Clinical Details:Measurements>>
SpO2: | <<Clinical Details:Measurements>>
Temperature: | <<Clinical Details:Measurements>>
Family history
<<Clinical Details:Family History>>
Social history
<<Clinical Details:Social History>>
Patient information
IHI: | <<Patient Demographics:IHI>>
Name: | <<Patient Demographics:Full Name>>
Date of birth: | <<Patient Demographics:DOB>>
Gender: | <<Patient Demographics:Gender>>
Indigenous status: | <<Patient Demographics:ATSI>>
Occupation: | <<Patient Demographics:Occupation>>
Patient's contact details
Residential: | <<Patient Demographics:Address>>
Postal (if different from above): | <<Patient Demographics:Address Postal>>
Home: | <<Patient Demographics:Phone (Home)>>
Mobile: | <<Patient Demographics:Phone (Mobile)>>
Does patient consent to SMS contact? | <<Does patient consent to SMS contact?>>
Interpreter required: | <<Patient Demographics:Requires Interpreter>>
Preferred language: | <<Patient Demographics:Language Preferred>>
Alternative Contact / Carer Details
Name: | <<Patient Demographics:Next of Kin>>
Relationship: | <<Patient Demographics:Next of Kin Relationship>>
Phone: | <<Patient Demographics:Next of Kin Phone>>
Are there custody or guardianship issues? | <<Are there custody/guardianship issues?>>
Details of custody/guardianship issues: | <<If yes, details of custody/guardianship issues>>
Is the child in and out of home (foster) care? | <<Is the child in and out of home (foster) care?>>
Name of child safety service centre: | <<If yes, name of child safety service centre>>
Does the patient have an advance care plan? | <<Does the patient have an Advanced Care Plan?>>
Does the patient have enduring power of attorney? | <<Does the patient have enduring power of attorney?>>
Insurance information
Medicare number: | <<Patient Demographics:Medicare Number>>
Medicare expiry: | <<Patient Demographics:Medicare Expiry Date>>
Pension number: | <<Patient Demographics:Pension Number>>
DVA number: | <<Patient Demographics:DVA Number>>
Health fund: | <<Patient Demographics:Health Insurance>>
Referring GP's information
Name: | <<Doctor:Name>>
Provider number: | <<Doctor:Provider Number>>
Practice details: | <<Practice:Name>>
Address: | <<Practice:Address>>
Phone: | <<Practice:Phone>>
Fax: | <<Practice:Fax>>
Email: | <<Practice:E-mail>>
I look forward to hearing the outcome of this patient's consultation.
Yours sincerely, |
<<Doctor:Name>> |

<<Patient Demographics:Title>> <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Version CQHHS SOPD Gladstone MD 1920Q4. Send feedback to CQHHS_GPLO@health.qld.gov.au.