Assessment and treatment of memory loss	    Referral Form

       Fax to (03) 6247 6439		

  PATIENT DETAILS
Surname: 	<<Patient Demographics:Surname>>	Given Names:	<<Patient Demographics:First Name>>	
Address: 	<<Patient Demographics:Full Address>>	Gender:	<<Patient Demographics:Sex>> 	
DOB:		<<Patient Demographics:DOB>>	Contact:	 (h) <<Patient Demographics:Phone (Home)>>  (m)  <<Patient Demographics:Phone (Mobile)>>	
Private Health Fund Name: <<Patient Demographics:Health Insurance>>	Membership No:	<<Health Insurance Membership No.>>	
Medicare No: <<Patient Demographics:Medicare Number>>		
Reason for referral: 

	
  NEXT OF KIN CONTACT DETAILS
Name:	<<Next of Kin>>	Relationship to Patient: 	<<Next of Kin, Relationship to patient.>>	
Phone: 	<<Next of Kin, Contact No.>>		
  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
 <<Clinical Details:History List>>
MEDICATIONS
<<Clinical Details:Medication List>>	
  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
<<Doctor:Full Details>>	Signature: 	Date: <<Miscellaneous:Date (short)>>	

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

<<Summary:Investigation Results (Selected)>>