REQUEST FOR MEDICAL DAY STAY UNIT 					FAX 03 4215 2302

GP Referral
		Referral Date: <TodaysDate>

Feedback Requested:  Yes	

Referral to:
Barwon Health Medical Day Stay Unit

Service requested: <Service Requested:>
Urgency:  <Urgency>		
Referral valid for: <Referral valid for>		Referring General Practitioner:
<DrName> 
<Practice>
<UsrAddress>
HPI-O: <PracHPIO>
Phone: <UsrPhone>   Fax: <UsrFax>
Email: <DrEmail>
Provider No.: <DrProviderNo>
HPI-I: <DrHPII>	

Consumer details:
Name:	<PtFirstName> <PtSurname>
Date of Birth:	<PtDoB>
Age:                        <PtAge>
Preferred Name/s:	<PtPrefName>
Sex:	<PtSex>
Title:	<PtTitle>
Pt IHI:                     <PtIHI>
		Contact Address:	<PtName>
	<PtStreet>
	<PtCity>  <PtState>    <PtPostcode>
Phone:	<PtPhoneH>
Work:	<PtPhoneWk>
Mobile:	<PtPhoneMob>
Email:	<PtEmail>

Alternative Contact: 

 
Interpreter required: <Does the patient require an interpreter?>		DVA Number: <PtDVANo>	
Preferred language is: <If interpreter needed, which language>		Insurance: <PtHealthIns>	
Pension Card Number: <PtPensionNo>		Medicare Number: <PtMCNo>	
TAC or Workcover? <TAC or Workcover?>			

Clinical Information:		<PtFirstName> <PtSurname> DOB:  <PtDoB>
HealthPathways Barwon provides guidance in patient assessment, management and referral.
<HealthPathways Barwon guidance in Mx Ax referral>	

Reason for patient referral: 
<Reason for Referral>

Cause of iron deficiency anaemia or provisional diagnosis:  <Cause of Fe deficiency or provisional Dx?>
Recent Hb:  <Recent Hb>
Recent MCV:  <Recent MVC>
Recent iron studies:  <Recent Fe studies>
Plan for GP  followup:   <Plan for GP followup>
Name of HMO/Registrar who has agreed to admission:  <Name of HMO or reg who agreed to admission?>

Previous relevant consultants or unit involved in Mx of problem or related problem:
<Previous consultant/s involved in Mx of problem>
Recent PHx Medication list review undertaken:  <Recent PHx Medication list review undertaken?>

Warnings: <Comment>

Allergies: <Reactions> 

Current Medication:
<RegularRx>

Social History: <SocialHx> 

Past Medical History: 
<PMHAll>

 ---------------------------------------------------------------------------------------------------------------------------------

Progress Notes: 
<Visits>

Investigation Results:
<Ix>

Did the HealthPathways website assist you in the assessment, management or referral of your patient?: <Did HealthPathways assist in Ax Mx referral of pt?>