Author: Sarah Wiles

REFERRAL- CARDIAC REHABILITATION | U.R No:
| TITLE: Patient Demographics.Title | SURNAME: Patient Demographics.Surname

All enquiries to (08) 8201 7840
Monday to Friday   9am – 5pm

SEND COMPLETED REFERRAL TO:
E-mail:  
Fax: (08) 8201 2597

GIVEN NAMES: Patient Demographics.First Name

| ALIAS: Patient Demographics.Popular Name
| D.O.B: Patient Demographics.DOB | GENDER: Patient Demographics.Gender
| MEDICARE NO: Patient Demographics.Medicare Number
| IHI: Patient Demographics.IHI Number
| DVA: | DVA NO: Patient Demographics.DVA Number
| Complete details or affix client identification label

Complete all relevant sections
Client/ Patient contact details | Address 1: Patient Demographics.Full Address | City/ Suburb: Patient Demographics.Suburb
| Address 2: | Postcode: Patient Demographics.Postcode | State:
| Phone: Patient Demographics.Phone (Home) | Mobile:Patient Demographics.Phone (Mobile)
| Aboriginal or Torres Strait Islander: Ethnicity
| E-mail: Patient Demographics.E-mail | Cardio Rehab: Cardio Rehab Nominated Cardiac Rehab Site: Cardio Rehab

Hospital admission details

Date of admission: Date of Admission

Date of discharge: Discharge Date 
Transferred to: Hospital Transfer

Inpatient Cardiac rehabilitation review

Was this person reviewed by a rehabilitation nurse whilst an inpatient in hospital? Inpatient details

Phase 1 completed:
Phase 1

Referrer details | Referrer: Miscellaneous.Current User | Date of Referral: Miscellaneous.Date
| Organisation: Practice.Name | Role: Current User

Cardiologist details

Cardiologist Name: 
Cardiologist Name

Organisation: Cardio Rooms

| Address: Address
| Phone:Phone | E-mail: Email
| Fax: Fax |
Client/patient's GP or other primary care provider details | Name: Treating Doctor.Name | Organisation: Practice.Name
| Address: Treating Doctor.Full Address
| Phone: Treating Doctor.Phone | E-mail: Treating Doctor.E-mail
| Fax: Treating Doctor.Fax |
Has the client/patient been given the following resources? | MY Heart MY LIFE: Resource
| MY HEART MY FAMILY OUR CULTURE: Resource
Principal diagnosis/reason for referral | Referral Reason
Current Medications | Clinical Details.Medications - Current Regular (with comments)
Relevant Medical History | Clinical Details.Problem List (Current)

Risk Profile
Test Date:

LDL: Cholesterol

HDL: HDL Chol

Trig: Trig

Total Chol: Total Chol

| Height: Height | Weight: Weight | Smoker: Clinical Details.Smoking | BP: Blood Pressure

_CATCH _Program _PHN _Country _SA _and _iCCnet _CHSA _initiative
_Address: _Level _2B _Mail _Box _25 _Mark _Oliphant _Building _Laffer _Drive _Bedford _Park _SA _5042