Sunshine Coast Hospital & Health Service
URGENT: COVID escalation of care
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Medical Objects:  NQ45600007J
Healthlink: qldnghop

PATIENT'S DEMOGRAPHIC DETAILS
Full name: 
Date of birth: 
Residential address: 
Phone – home:                  mobile:                 alternate: 
Medicare number, where eligible:                            Expiry: 
NOK:                             relationship:  
NOK phone:                      alternate: 
Preferred language:                              interpreter required: 
Identifies as Aboriginal and/or Torres Strait Islander: 

PRACTITIONER DETAILS
Full name: 
Full address: 
Phone:                  Fax:                Email: 
Provider number: 
Date of request: 

COVID-19 HISTORY
Date of positive test: 
Type of test: 
Date of first symptoms: 
COVID-19 vaccination status (number of doses received): 
Reason test could not be performed (if applicable): 
 
RELEVANT CLINICAL INFORMATION
Current symptoms: 
Reason for escalation of care: 
Medical risk factors: 
Social risk factors: 
 
STANDARD CLINICAL INFORMATION
Allergies: 

Past Medical history: 

Current medications:

Immunisations: