FOR MEDICAL RECORD USE ONLY

-MEDICAL RECORD COPY –	

South Eastern Sydney Illawarra Area Health Service 	

Access and Referral Intake Form  	

SURNAME:                                           MRN:
OTHER NAMES:
DOB:                        SEX:                     AMO:

AFFIX PATIENT ID LABEL HERE
      	
Referrer Details
Referred by (Name):	 <<Doctor:Name>>	Contact No:	 <<Doctor:Phone>>	
Designation/Organisation/Relationship		
Ward:		Hospital:		
In Hospital Assessment	 Yes q  Noq 	AMO Details:		
Hospital Discharge Date:		Date of Referral:	   <<Miscellaneous:Date (short)>>	
Date Service to Commence:		Medical/Nursing Discharge Summary Attached:	  q 	
Patient /Client Details
Surname:   <<Patient Demographics:Surname>>	Given Names:     <<Patient Demographics:First Name>>	
DOB:           <<Patient Demographics:DOB>>	Male/Female:        <<Patient Demographics:Sex>>	
Marital Status:      Married/De factoq Never Marriedq  Separatedq Divorcedq Widowq Unknownq 	
Mothers Given and Surname (C& F Referrals Only):     	
Temporary/ Discharge Address:    	
Suburb:    	Home No:    <<Patient Demographics:Phone (Home)>>	
Work No:    <<Patient Demographics:Phone (Work)>>	Mobile No:    <<Patient Demographics:Phone (Mobile)>>	
Permanent Address:    <<Patient Demographics:Address Line 1>> <<Patient Demographics:Address Line 2>>	
Suburb:  <<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>	Home No:  <<Patient Demographics:Phone (Home)>>	
Aboriginal or Torres Strait Islander Descent?   
     q No         q Yes       Please specify à      q Aboriginal          q Torres Strait Islander       q  Both	
Country of Birth: 	Religion:	
Preferred Language: 	Interpreter Required: Yes q  No q 	
GP Details
GP Name:	 <<Doctor:Name>>	Provider No.	 <<Doctor:Provider Number>>	
Phone No:	 <<Doctor:Phone>>	Fax No:	 <<Doctor:Fax>>	
Address:	 <<Doctor:Address Line 1>> <<Doctor:Address Line 2>> 	
Suburb: 	 <<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>	Is GP Aware of Referral:	   Yes q No q	
Details of Person to Contact
Contact name:		
Relationship to patient:		
Carer: 	     Yes q No q	Mobile No:		
Home No: 		Work No: 		
Address:		
Financial Details
Medicare No:	 <<Patient Demographics:Medicare Number>>	Medicare Ineligible:	 Yes q No q	
DVA No:	 <<Patient Demographics:DVA Number>>	Card Colour: 	 Gold q White q	
Pension Type:	 Aged q    Disability Support q    Other q <<Patient Demographics:Pension Number>>	

FOR MEDICAL RECORD USE ONLY

-MEDICAL RECORD COPY –	

South Eastern Sydney Illawarra Area Health Service 	

Access and Referral Intake Form  	

SURNAME:                                           MRN:
OTHER NAMES:
DOB:                        SEX:                     AMO:

AFFIX PATIENT ID LABEL HERE

Diagnosis/Medical History (include any other relevant details- co-morbidities, test results)	
<<Clinical Details:History List>>
Multi-Resistant Organism and/or Infection Alert:    Yes q No q  Type/Site:		
Biohazard Alert: 		
Allergies:	
<<Clinical Details:Allergies>>
Services Requested/ Patient Needs: (description of problem and/or issue, including current management/treatment)	

Hospital Dischargeq     Fallsq   Acute Medical Conditionq     Carer Burden q  Increasing Frailtyq   Otherq  	
Other referrals made: (include services and contact details)	

Other Community Services Already Received (include services and other contact details) 	

Current ACCR    Yes q No q    High Level q     Low Level q     Respite q     CACPq      EACHP/Dq 	
Communication Impairment: 
Speech: Yes q	 No q
Hearing: Yes q	 No q
Vision:   Yes q	 No q
Aids: 	Cognition:
Orientated Yes q No q
Confused: 
New q   Old q   Deterioration q
Dementia Diagnosis:
Yes q No q
	Mobility:	
q Independent  
q Independent with aid
q Assist x 1 
q Wheelchair  
q Bed bound  	Personal Risk Assessment:
Verbally threatening:  Yes q No q
Acts of aggression:    Yes q No q
Sexual harassment:   Yes q No q
Other:
 	
Social:	 
Lives Alone:                               Yes q    No  q
Does the patient have a carer:  Yes q    No  q
Is carer in hospital or away:      Yes q     No q
Relationship: 
Is the patient a carer:                Yes q     No q	Palliative Diagnosis:
Yes     q No q
End Stage  Yes q No q
Diagnosis:	Continent:       Yes q No q
SPC q     IDC q      N/A  q
Self Caring  Yes q No q	
Transport Required:      Yesq Noq	Is patient able to:  Get in/out of car q   On/off bus  q Stretcher required q 	
Ambulatory Care Unit AMO Only:    AMO:		Date: 		
Requesting M.O Signature:		Print name: 		
OFFICE USE ONLY	
Service:	Case Manager	Date Received: