Referral Form
HeartStart Program 
Fax: 4150 1888
Medical Objects: CH4670000QJ

Patient Details:
Name:   <<Patient Demographics:Full Name>>	DOB:   <<Patient Demographics:DOB>>	
Address:   <<Patient Demographics:Address>>	Contact No:   <<Patient Demographics:Phone (Home)>>	
NOK:   <<Patient Demographics:Next of Kin>>	Mobile:   <<Patient Demographics:Phone (Mobile)>>	

Patient Current Medications:
<<Clinical Details:Medication List>>

Patient status:
Stable Angina: <<Stable angina>>
Bypass surgery: <<Bypass surgery>>
Post Infarct: <<Post infarct>> 
Post-stent/Angioplasty: <<Post-stent/Angioplasty>> 
Post valve/Function: <<Post valve/Function>>
CHD/Heart failure: <<CHD/Heart failure>> 

Identified coronary risk factors:
<<Coronary risk factors>>
Hypertension: <<Hypertension>>
Diabetes Mellitus: <<Diabetes Mellitus>>
High cholesterol: <<High cholesterol>>
Smoking: <<Smoking>>
Family history HD: <<Family history HD>>
Depression: <<Depression>>

Additional Problems/Other:  <<Other>>

Functional Assessments:
Recent exercise test results included: <<Exercise test results attached>> 
Exercise tests have not been performed but patient exercise is recommended: <<Patient exercise recommended>> 

Other medical problems which preclude walking as an exercise: <<Medical problems precluding walking as exercise>> 
Osteo-arthritis - knees/hips: <<Osteo-arthritis - knees/hips>>
Back problems: <<Back problems>>
Recommend water aerobic exercises: <<Recommend water aerobic exercises>>

Referred by:
<<Doctor:Full Details>>

Date of Referral: <<Miscellaneous:Date>> _____________________________________________________________________