e e GNEw9010 44L SERV0010 GNEwMGNEw9010GNEwTGNEw9010: Hospital Administration Use Only: Affix patient label hereGNEwCGNEw9010GNEwBGNEw9010GNEwTGNEw9010GNEwFGNEw9010TRPwTabulationsTRPw0010IRPXIRPU Rt dXXIRPW\\GPQSVR04VM04\Utilities RICOH C 4dXXA4FNIwE1FNIw0010 oMRPwMRPw4010w.A ++HHHH?XIPwNumberFormats XIPw301BORPwPPRPw1010  TNFwN`TNFw0010Times New RomanArial Arial NarrowTimes New Roman CETimes New Roman CyrTimes New Roman GreekTimes New Roman TurTimes New Roman (Hebrew)Times New Roman (Arabic)Times New Roman BalticTimes New Roman (Vietnamese)Arial CE Arial Cyr Arial Greek Arial TurArial (Hebrew)Arial (Arabic) Arial BalticArial (Vietnamese)Arial Narrow CEArial Narrow CyrArial Narrow GreekArial Narrow TurArial Narrow BalticLTSwNormalLTSw0010PRPw1010  TTSw1010ABATw2010Times New Roman@@@@d@@@@@@@@h@D@ @ CAIRNS BASE HOSPITAL OUTPATIENT REFERRAL FORM v10/12 =========================================================================== REFERRAL:  Date of referral: ] JBO5/ #$y@@Referral validity duration: >AAAA12 months >AAAA3 months >AAAAIndefinite >AAAAAssessment & referral back  Reason for referral:  @@7@@$# =========================================================================== @@7REFERRAL TO:  Organisation: Cairns Base Hospital CENTRAL REFERRAL OFFICE (CC4870000GB) Clinic referred to: Doctors Name: List of Specialists: ]PN4KLHw00107RW4Link CBH Referral Guide for GPsHhttp://www.health.qld.gov.au/cairns_hinterland/docs/pro_gp_ref_guide.pdfLink CBH Referral Guide for GPsURL:http://www.health.qld.gov.au/cairns_hinterland/docs/pro_gp_ref_guide.pdf   Clinic referred to (where no specific doctor has been nominated):   Address: PO Box 902, Cairns Phone: 07 4226 8984 Fax: Surgical 07 4226 6843 Womens Health 07 4226 9513 Paediatrics 07 4226 6714 Endoscopy, Medical & Aged Care 07 4226 8981 Mental Health 07 4226 3149 Diabetes 07 4226 4637 @@7=========================================================================== @7@REFERRAL FROM:  Referring clinician: ] JBO5  Organisation: ] JBO5 Address: ] JBO5, ] JBO5, ] JBO5, ] JBO5 Phone: ] JBO5 Email: ] JBO5 Fax: ] JBO5 Provider number: ] JBO5 ! @7@=========================================================================== @@7PATIENT DETAILS: Re: ] JBO5& Surname: ] JBO5 Given name: ] JBO5 DOB: ] JBO5 Sex: ] JBO5 Preferred language: Interpreter required:   Indigenous status:  @@ >AAAANeither Aboriginal nor Torres Strait Islander >AAAAAboriginal but not Torres Strait Islander >AAAATorres Strait Islander but not Aboriginal >AAAABoth Aboriginal and Torres Strait Islander >AAAANot Stated/Unknown @$@ Australian South Sea Islander status: @@@$@>AAAAYes >AAAANo  @@Address: ] JBO5U ] JBO5, ] JBO5, ] JBO5+, ] JBO5, @@@@'Phone (home): ] JBO5 @@@@'Phone (work): ] JBO5! Phone (mobile): ] JBO5J Medicare card number: ] JBO5' DVA card number: ] JBO5# #h$@@@@$ Compensable status:  @@$\#@#@$>AAAAEligible Public $#@$@#@@>AAAAEligible Third Party (Motor Vehicle Third Party Insurance / Third Party Insurance) >AAAAWCBQ Eligible Compensable (Qld Workers' Compensation Act / Other Workers' Compensation Act) >AAAAOther Eligible Compensable (Under the Criminal Code) >AAAAEligible Other (Private patient) @@$@@#$y Hospital insurance status: @@#$@@>AAAAYes #$y@@>AAAA>AAAANo @@Private health insurance fund: ] JBO5: @@7@@$# =========================================================================== @@7PATIENT CLINICAL INFORMATION: Current medications: (please list and provide description, dosage, route, dose quantity, frequency and any additional instructions) @2@ Current Medications: ]ddVJBO5DNKOTNRTX  Show_Scripts @2@  Warnings / alerts:  Allergies/ adverse reactions: (Please list and including reaction description)  Allergies: ]ffXJBO5FNKOTNRTX Show_Allergies  Recent investigations / test results: (including type, name, date, result status, results)  Smoking status: ] JBO5j Alcohol consumption: ] JBO5  Existence of Advanced Healthcare Directive: @7@=========================================================================== @@7PATIENT CLINICAL HISTORY: Relevant medical and surgical history: (including treatments, medications, outcomes, date/time range) Relevant social:(including employment, education, home, finances and activities of daily living)   Relevant family history:  @@2 ] JBO5 @2@ Special needs and/or psychosocial issues: @7@=========================================================================== @@7USUAL GP (if different): @9@@@Name and Organisation: ] JBO58 @7@U@M@ @9@Contact details: @@@ @7@@M@U@7=========================================================================== @@7ALTERNATE CONTACT(S): @Z@#@@@@Alternate Contact name (First name, Family name): ] JBO5F Relationship to patient: @@'@#@ZAlternate Contact contact details: ] JBO5G @@7@@'=========================================================================== @@7VERIFICATION: @2@ Doctors Full Name: ] JBO5  @@2Date: ]zzlJBO5ZNKOTNRTX& Show_CurrentDaten@n @7@=========================================================================== @@7Sent via STS Secure electronic transfer to: CAIRNS BASE HOSPITAL @)@Form version: 06/11 >CCCC