REFERRER DETAILS
Name:	<DrName>     	Organisation:	<Practice>     	
Job Title:	  GP   	Phone:	<DrPhone>   	Mobile:	<DrMobilePhone>	
Email:	 <DrEmail> 	Fax:	<DrFax>     	Date of referral:	<TodaysDate> 	

CLIENT DETAILS
Full Name:	 <PtName>	Date of Birth:	<PtDoB>	URN:		
Address:	 <PtAddress>					
Phone:	<PtPhoneH>	Mobile:	<PtPhoneMob>	Email:	<PtEmail>	
Has Client consent been obtained?	 <Has Consent been obtained ?>	Has Client received a CCRPHP Fact sheet?	<Has Client received a CCRPHP Fact sheet?>	
Gender:	 <PtSex>	Ethnicity:	 <PtEthnicity>	Interpreter required:	 <Interpreter Required>  <Language Spoken>	
GP Name:	 <DrName>	GP Practice:	 <Practice>	GP Phone:	<DrPhone>	

CARER DETAILS
Name:	  <Carer Name>	Relationship to Client:	  <Carer Relationship to Client>	
Address:	 <Carer Address>   	Phone:	 <Carer Phone Contact>   	
Next of Kin Details (if different from carer)	 <NOKName>  <NOKContact>	

Chronic Disease(s) (mark with "x" all that apply)
								
	 Cardiovascular		 Respiratory		 Musculoskeletal		 Diabetes	

Vital signs data to be shared with (if applicable) (mark with "x" all that apply)
								
	 GP		 Practice Nurse		 Community Nurse		 Other	
								
Name:		 Fax:		
Phone:		 Mobile:		
Email:		 Emergency Contact:	     YES/NO	

SERVICE STREAM REQUESTED: (mark with "x" all that apply) 
		    All clients referred to the CCRPHP receive care coordination from our Clinical Care Coordinators	
			
		  Allied Health Services         (Specify below)	
			
		  Tele-monitoring Services (Please complete page 3-5 if required)	

Health Summary

Medical History	
<SelectedPMH>	
Medications	
<SelectedRx>	
Allergies	
<Reactions>	
Immunisations	
 <Imm>	
Social History and Circumstances	
<SocialHx>	

This section is only required to be completed if a tele-monitoring service is requested.	

Corumbene Care Rural Primary Health Program is offering a 6 – 12 week tele-monitoring service for Clients, to assist self-management of their chronic conditions.  CCRPHP’s Clinical Care Co-ordinators (RNs) monitor all Client data which is collected via an easy-to-use personal computer tablet (myclinic hub).  The hub enables the Client to access a customised health interview which guides them through a series of measurements and pre-set health questions.   The hub automatically collects information from peripheral devices through Bluetooth technology, infrared or serial cable.
The peripheral devices available for vital signs monitoring are:-
		Blood pressure monitor	
		
		Pulse oximeter	
		
		Weight Scale	
		
		Blood glucose monitor	
		
		Thermometer	
		
		Peak flow/lung monitor	
		
		A limited number of ECGs & coagulation meters may also be available - please call the CCRPHP	
	   to discuss if these are required. 	

Please indicate above, which peripheral devices you would like the Client to be provided with.  Vital signs measurement data reports can be sent to you as frequently as you would like.
In the table below, please indicate the chronic condition you would like monitored, the frequency and preferred monitoring timeframes.   Please also provide details of the Client’s vital signs parameters and limits.

Preferred vital signs check	
	 Chronic Condition Health Interview	 Times	
 Monday		AM	PM	
 Tuesday		AM	PM	
 Wednesday		AM	PM	
 Thursday		AM	PM	
 Friday		AM	PM	
	
Vital	SBP	DBP	Pulse	Oximetry	Temp	Glucose	Weight	FEV1	FEV6	
Upper limit										
Lower limit										
Target level
(if track and trend)										

Please attach a discharge summary if applicable

Tele-monitoring facilities may also be available for multi-users.
For further information and assistance please contact Corumbene Care Rural Primary Health Program	

 Tele-monitoring Basic Packs  (Please mark with "x" as required)	

			HF pack	

Interview type			Heart failure general (includes oedema & chest pain)			
					
			Heart failure chest pain only		  Heart failure oedema only	
					
Peripherals	  Blood Pressure cuff (specify):		 Sml (17-32cm)		  Med (22-42 cm)		 Lrg (32-45 cm)	
								
			  INR Monitor		  Weight Scales		  Oximeter	
								
			  ECG (Optional)					

			
			COPD pack	

Interview type			COPD general		  COPD Oxygen	
					
					  COPD chest pain	
			COPD sputum			
					
Peripherals	  Blood Pressure cuff (specify):		 Sml 		  Med 		 Lrg 	
								
			  Weight Scales		  Oximeter		  	
								
			 Lung monitor (Optional)		  Thermometer (optional)			

			
			Diabetes pack	

Interview type			Diabetes Vision		  Diabetes footcare	
					
			Diabetes general with hypo		  Diabetes UTI	
					
Peripherals	  Blood Pressure cuff (specify):		 Sml 		  Med		 Lrg 	
								
			  Weight Scales		  Oximeter		  Glucometer	

			
			Hypertension pack	

Interview type	 Hypertension		  	
				
Peripherals	  Blood Pressure cuff (specify):		 Sml 		  Med		 Lrg 	
								
			  Oximeter (optional)		  Weight Scales (optional)		  	

			
			Pain pack	

Interview type	 Pain		  	
				
Peripherals	  Blood Pressure cuff (specify):		 Sml 		  Med		 Lrg 	
								
			  Other		  		  	
								
						                 (Optional):			

 Combination Packs  (Please mark with "x" as required)	

			COPD + Diabetes	

Interview types included	COPD and Diabetes			
				
Peripherals	  Blood Pressure cuff (specify):		 Sml		  Med		 Lrg	
								
			 Weight Scales		  		  	
								
			  Oximeter					
								
			  Glucometer					
								
			  		 Thermometer	(opt	ional)	
								
			  Lung Monitor (optional)					

			
			COPD + HF	

Interview types included	COPD and CHF			
				
Peripherals	  Blood Pressure cuff (specify):		 Sml		  Med		 Lrg	
								
			  Weight Scales		  		  	
								
			  Oximeter					
								
			  Lung Monitor (optional)		 Thermometer	(opt	ional)	
								
			  ECG (optional)		 INR Monitor			

			
			HF + Diabetes	

Interview types included	HF and Diabetes			
				
Peripherals	  Blood Pressure cuff (specify):		 Sml		  Med		 Lrg	
								
			 Weight Scales		  INR Monitor		  	
								
			  Oximeter					
								
			  Glucometer					
								
			  ECG (optional)