Community Continence Service Referral form

<<Please Select region>>
Client Surname: <<Patient Demographics:Surname>>	Given names: <<Patient Demographics:First Name>>	DOB: <<Patient Demographics:DOB>>	Gender: <<Patient Demographics:Sex>>	
Address: <<Patient Demographics:Address>> <<Patient Demographics:City>> <<Patient Demographics:Postcode>>	
Home Ph: <<Patient Demographics:Phone (Home)>>	WorkPh: <<Patient Demographics:Phone (Work)>>	Mobile: <<Patient Demographics:Phone (Mobile)>>	
GP: Name: <<Doctor:Name>>	            Profession: General Practitioner
Contact details: <<Practice:Name>>	<<Practice:Address>>	Ph:<<Practice:Phone>>	Fax: <<Practice:Fax>>	
	
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:   <<Clinical Details:History List>>	
	
Medications:   <<Clinical Details:Medication List>>	
	
Allergies:  <<Clinical Details:Allergies>>	
	
Urinalysis:   		Date: 	
	
Usual Bowel elimination pattern:     	
	
Interventions that have been implemented to address current urinary / faecal elimination problem(s)   

Client name:  <<Patient Demographics:Full Name>>   Referred by GP:  <<Doctor:Name>>           
Contact details: <<Practice:Name>>	Ph:<<Practice:Phone>>	Fax: <<Practice:Fax>>

Signature:
													Date: <<Miscellaneous:Date>>