Hospital Administration Use Only: Affix patient label here

WBHHS  OUTPATIENT REFERRAL FORM
===========================================
PATIENT DETAILS:
Re: <PtFullName>
Surname: <PtSurname>   
Given name: <PtFirstName>
DOB: <PtDoB>
Sex: <PtSex>
Preferred language: <Preferred Language>
Interpreter required: <Interpreter required>
Indigenous status: <PtEthnicity>
Australian South Sea Islander status: <Australian South Sea Islander status>
Address: <PtStreet> <PtCity> <PtState> <PtPostcode>
Phone (home): <PtPhoneH>
Phone (work): <PtPhoneWk>
Phone (mobile): <PtPhoneMob>
Medicare card number: <PtMCNo> Line: <PtMCLine> Expiry:<PtMCExpiry>
DVA card number: <PtDVANo> <PtDVACard>
Compensable status: <Compensable status>
Hospital insurance status: <Hospital insurance status>
Private health insurance fund: <PtInsFund> <PtInsNo>
=================================================
REFERRAL TO:
Organisation: 
<Organisation referring to>
Clinic referred to: <Clinic referred to (Bundaberg)><Clinic referred to (Hervey Bay)><Clinic referred to (Maryborough)> <Referral to (type name here if not selected above)>
=================================================
REFERRAL FROM:
Referring clinician: <DrName>
Organisation: <Practice>
Address: <DrStreet> <DrCity> <DrState> <DrPostcode>
Phone:<DrPhone>
Email: <DrEmail>
Fax: <DrFax>
Provider number: <DrProviderNo>
=================================================
REFERRAL: 
Date of referral:<TodaysDate>
Referral validity duration: <Referral validity duration>
Reason for referral: <Reason for referral>
=================================================
PATIENT CLINICAL INFORMATION:
Current medications: (please list and provide description, dosage, route, dose quantity, frequency and any additional instructions)
<SelectedRx>Warnings / alerts: <Warnings/Alerts?>
Allergies/ adverse reactions: (Please list any including reaction description)
<Reactions>
Recent investigations / test results: (including type, name, date, result status, results) 
<Ix>
Existence of Advanced Health Directive: <Existence of Advanced Health Directive>
=================================================
PATIENT CLINICAL HISTORY:
Observations: <Observations>
Relevant medical and surgical history: (including treatments, medications, outcomes, date/time range)
<SelectedPMH>
Relevant social / family history: (including employment, education, home, finances and activities of daily living)
<SocialHx>
<FamilyHx>
Special needs and/or psychosocial issues: <Special needs and/or psychosocial issues>
=================================================
USUAL GP (if different):
Name and Organisation: <Usual GP Name and Organisation (if different)>
Contact Details: <Usual GP Contact Details (if different)>
=================================================
NEXT OF KIN:
Next of Kin name: <NOKName> 
Relationship to patient: <NOKRelation>
Contact details: <NOKContact> <NOKContact2>
=================================================
VERIFICATION:
Doctors Full Name: <DrName>
Date: <TodaysDate>
=================================================
template version 0921BP, maintained by CQ,WB,SC PHN