Re: <PtFirstName> <PtSurname>   DOB: <PtDoB>

Central Queensland Hospital and Health Service
Hospital in the Home/Virtual Ward,
Positive COVID-19 Referral

PATIENT'S DEMOGRAPHIC DETAILS
Title: <PtTitle>
First name: <PtFirstName>
Preferred name: <PtPrefName>
Middle name: <PtMidName>
Surname: <PtSurname>
Date of birth: <PtDoB>
Residential address: <PtAddress>
Phone – home: <PtPhoneH>   mobile: <PtPhoneMob>       alternate: 
Medicare number, where eligible: <PtMCNo> / <PtMCLine> Expiry: <PtMCExpiry>
Name of the parent or caregiver, NOK: 
NOK: <NOKName>      relationship: <NOKRelation>
NOK phone: <NOKContact>      alternate: <NOKContact2>
Preferred language: <Preferred language>   interpreter required: <Interpreter required>
Identifies as Aboriginal and/or Torres Strait Islander: <Aboriginal and/or Torres Strait Islander Status>

PRACTITIONER DETAILS
Full name: <DrName>
Full address: <DrAddress>
Phone: <DrPhone>   Fax: <DrFax>   Email: <DrEmail>
Provider number: <DrProviderNo>
Date of request: <TodaysDate>

COVID-19 HISTORY
Date of positive test: <Date of positive COVID-19 test>
Type of test: <Type of test>
Date of first symptoms: <Date of first symptoms>
Fully vaccinated against COVID-19?: <Fully vaccinated against COVID-19?>
 
RELEVANT CLINICAL INFORMATION
Current symptoms: <Current symptoms>
Reason for escalation of care: <Reason for escalating care>

STANDARD CLINICAL INFORMATION
Allergies: 
<Reactions>

Past Medical history: 
<SelectedPMH>

Current medications:
<SelectedRx>

Immunisations:
<Imm>

Please email all referrals to the CQHHS COVID HiTH Virtual Hospital CQHHS_CANAS@health.qld.gov.au or Fax 4920 7029. Phone 49206211 for the CQHHS COVIDHiTH Virtual Hospital SMO. For deteriorating patients requiring urgent medical attention, please call 000 and advise of COVID positive status.