Assessment and treatment of memory loss	    Referral Form

       Fax to (03) 6247 6439		

    PATIENT DETAILS
Surname: 	<PtSurname>	Given Names:	<PtFirstName>	
Address: 	<PtAddress>	Gender:	<PtSex> 	
DOB:		<PtDoB>	Contact:	 (h) <PtPhoneH>  (m)  <PtPhoneMob>	
Private Health Fund Name: <PtHealthIns>	Membership No:	<PtInsNo>	
Medicare No: <PtMCNo>		
Reason for referral: 

	
    NEXT OF KIN CONTACT DETAILS
Name:	<NOKName>	Relationship to Patient: 	<NOKRelation>	
Phone: 	<NOKContact>		
    OTHER DETAILS
Enduring Power of Attorney:	  <Enduring Power of Attorney>		
Enduring Guardianship:	  <Enduring Guardianship>	
ACAT Status	 q	High		q	Low		q	Residential		q	Respite		
ACAT Assessment Date:	  	
Services provided at home:		
Means of Transport	  		
Issues of concern 	  q	Falls		q	Cognition	q	Continence	
(mark all and detail any others)	  q	Symptoms of Dementia (BPSD)		q	Psychiatric illness		
	  q	Functional limitations	q	Family Stressors		
	  q	Safety concerns	q	Others - detail............................		
    SUMMARY OF MEDICAL HISTORY/CURRENT MEDICATIONS
 <SelectedPMH>
MEDICATIONS
<SelectedRx>	
    GP ASSESSMENT & ATTACHED PATHOLOGY
MMSE Score	<MMSE Score>	Bloods *	<Releveant Blood reports attached (see form)>	MSU	 <Mid stream Urine attached>	CT Brain	<C/T Brain scan attached>	
      * (FBC, U&E, LFT, TFT, B12/folate, iron syudies, cholesterol, fasting BSL)
     REFERRER DETAILS
<DrDetails>
Ph: <DrPhone>  Fax: <DrFax>
Prov: <DrProviderNo>	Signature: 	Date: <TodaysDate>	

City Practice:  8/39 Murray St, Hobart            Eastern Shore Practice: 31 Chipmans Road, Rokeby
www.tasmemoryclinic.com.au  l  Ph: (03) 6246 6060  l  Fax: (03) 6247 6439	

Pathology Results

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