Community Continence Service Referral form

<Please Select region>
Client Surname: <PtSurname>	Given names: <PtFirstName>	DOB: <PtDoB>	Gender: <PtSex>	
Address: <PtStreet> <PtCity> <PtPostcode>	
Home Ph: <PtPhoneH>	WorkPh: <PtPhoneWk>	Mobile: <PtPhoneMob>	
GP: Name: <DrName>	            Profession: General Practitioner
Contact details: <Practice>	<DrStreet>	<DrCity>  <DrPostcode>  Ph:<DrPhone>	Fax: <DrFax>	
	
Contact Person: (other than client)  	
Relationship to Client:   	Phone:  	
	
Client/Carer agrees to referral:       YES    r   NO    r	Home visit required    r  Can attend Clinic    r	
	
Ethnicity:	Language spoken:	Interpreter Req:   YES    r NO    r	
Identifies self as: 		Aboriginal    r   Torres strait Islander    r		Both    r	
	
Pension Type:	Benefit No:     	
Employee		r 		Self funded retiree    r   MAIB    r		Workers Compensation    r	
	
Other Services accessed:  	
	
Reason for referral: 

Onset of Problem:   

Health history:   <SelectedPMH>	
	
Medications:   <SelectedRx>	
	
Allergies:  <Reactions>	
	
Urinalysis:   		Date: 	
	
Usual Bowel elimination pattern:     	
	
Interventions that have been implemented to address current urinary / faecal elimination problem(s)   

Client name:  <PtName>   Referred by GP:  <DrName>           
Contact details: <Practice>	Ph:<DrPhone>	Fax: <DrFax>

Signature:
													Date: <TodaysDate>