SUTHERLAND HOSPITAL OUTPATIENT CLINICS

FAX TO: 9540 8067
PHONE ENQUIRIES: 9540 7067	

REFERRAL DATE: 		<TodaysDate>

OUTPATIENT CLINIC SERVICE: 	<Clinic referring to>

<<Choose from below>>
DIABETES
<Diabetes Outpatient Clinic>
	RENAL
<Renal>	RESPIRATORY FAILURE
<Respiratory Failure>	
ENDOCRINE
<Endocrine>	RENAL PALLIATIVE CARE
<Renal Palliative Care>
	RESPIRATORY OPC
<Respiratory Outpatient Clinic>	
REHABILITATION
<Rehabilitation>
	NEUROLOGY
<Neurology>	RESPIRATORY ASSESSMENT
<Respiratory Assessment>	

	NEUROLOGY/ REBABILITATION
<Neurology/Rehabilitation>	SLEEP CLINIC
<Sleep Clinic>	

REASON FOR REFERRAL (Mandatory For ALL Referrals)
<Reason for referral>	IF PATIENT HAS DIABETES, PLEASE SPECIFY TYPE OF DIABETES

<If patient has diabetes please specify type of diabetes>

REFERRING DOCTOR
NAME: <DrName>	PROVIDER	<DrProviderNo>	
ADDRESS:
<DrAddress>	PHONE
FAX
EMAIL	<DrPhone>
<DrFax>
<DrEmail>	

PATIENT INFORMATION
NAME: <PtName>
	GENDER :  <PtSex>
                    	
COUNTRY OF BIRTH: <Country of Birth>	DATE OF BIRTH: <PtDoB>	
ADDRESS
<PtAddress>	HOME: <PtPhoneH>	

WORK: <PtPhoneWk>	

MOBILE: <PtPhoneMob>	

E-Mail <PtEmail>	

MEDICARE NUMBER
<PtMCNo>	PENSION NUMBER
<PtPensionNo>	
DVA NUMBER
<PtDVANo>	HEALTH INSURANCE
<PtHealthIns>	

TRANSLATOR REQUIREMENTS	 <Translator Required>	LANGUAGE 	 <Language Required>	

PATIENT CONSENT	   <Patient Consent>	ABORIGINAL or TSI 	 <Aboriginal or TSI>	

CLINICAL INFORMATION
PAST MEDICAL HISTORY	

<SelectedPMH>

ALLERGIES

<Reactions>	

CURRENT MEDICATIONS

<SelectedRx>	

INVESTIGATIONS

<Ix>	

SOCIAL HISTORY

<FamilyHx>

SMOKING STATUS
<SmkStatus><SmkHx>	ALCOHOL USE
<AlcHx>	
EXERCISE 
 <Exercise>	DIET 
 <Diet>	

GP SIGNATURE		DATE