CQHHS PODIATRY REFERRAL FORM
Central Queensland Hospital & Health Service (CQHHS)  
Secure electronic transfer for CQ Referral Centre
Medical Objects: (XR4700000LZ)
HealthLink EDI: (qldrocop)
Or, fax to the CQ Referral Centre: (1300 017 155)

The above fax number cannot be used for Emergency Department
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:	<<Service provider>>	
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  	
Condition	
<<Condition referred for>>	
	
History and examination	
Medication list: 		
<<Clinical Details:Medication List>>	
	
Investigations relevant to this referral - results <3months old at time of referral	
HbA1c, FBC, ESR, CRP, Wound biopsy	
<<Summary:Investigation Results (Selected)>>	
	
Imaging and reports	
X-ray, Duplex Arterial Ultrasound, Bone Scan	Vascular Studies, MRI	
Have medical images been transferred to the hospital system?	<<Havel images been transferred to hospital system?>>	
	
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>>