Referrals : Swan Hill District Health

Todays Date *

Name of person requiring services: *

First

Last

Title: *

Date of Birth: *

Sex at Birth: *

Gender Identity: *

Country of Birth: *

Spoken language at home: *

Do you need an interpreter?: *

ATSI status: *

Are you a refugee or seeking asylum? *

Residential Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Accommodation type: *

Living arrangements: *

Preferred Phone number: *

Email:

Postal address as above?: *

Postal Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How should we contact you: *

If this referral is for a child, is the child living in out of home care?

Yes
No

Eligible for Medicare?:

Yes
No

Medicare number:

Medicare reference number:

Medicare care expiry date:

Do you have a carer? *

Carer's Name: *

First

Last

Carer's Relationship to patient: *

Carer's Phone number: *

Carer's Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Carer's Email (if applicable):

Have you been in hospital in the past 30 days? *

GP Name and name of Practice/Clinic: *

Do you have a Department of Veterans Affairs Gold Card? *

If yes, please provide your card number and expiry:

Do you have an NDIS plan? *

Are you registered with My Aged Care? *

If yes, please provide your MAC ID (AC number): *

Do you have a home care package? *

Who is your home care package provider? *

Do you have a Disability Support Pension? *

Referral for: *

Have you been diagnosed with: *

Type 1
Type 2
Gestational
Pre-Diabetes

Newly diagnosed? *

Is this referral for an adult or child? *

Do you receive a disability pension or care for someone who receives a disability pension? *

Does your child have a feeding or swallowing difficulty? *

Is your child stuttering? *

Does your child have difficulty talking or unclear speech? *

Does your child have difficulty understanding what you say? *

Does your child have any behaviours we need to know about? (Please detail below) *

Please provide further detail: *

Expected year of commencing school: *

Is this referral for an adult or child? *

Do you have a communication difficulty from a recent event? (e.g. stroke, fall etc.) *

Do you have a long standing communication difficulty? (e.g. voice, stroke occurring years ago, Parkinson’s Disease, etc) *

Do you have difficulty swallowing? *

How long have you had difficulty swallowing? *

Do you cough or choke when eating or drinking? *

Do you have difficulty chewing? *

Does your child have a feeding or swallowing difficulty? *

Is your child stuttering? *

Does your child have difficulty talking or unclear speech? *

Does your child have difficulty understanding what you say? *

Does your child have any behaviours we need to know about? (Please detail below) *

Expected year of commencing school: *

Type of Physiotherapy Referral *

Why would you like to see a Physiotherapist? *

Have you had a broken bone or surgery for muscles or joints in the last 6 months? *

Have you been referred for a chest infection? *

Have you had a fall in the last 6 months? *

Does your condition impact on your ability to care for people, complete daily tasks or work? *

If yes, please provide further information *

Do you receive package funding to assist your daily living? *

If yes, please provide Case Manager and phone number *

How long have you had this issue for? *

How severe is your pain (please tick) *

Mild
Moderate
Severe

Are you wanting an antenatal or post natal physiotherapy review? *

How many weeks gestation are you currently? *

What is your expected due date? *

Would you be interested in a Labour Tens Machine? *

Did you have: *

What was baby's Date of Birth? *

Were any instruments used during the delivery? (ie forceps or vacuum) *

Did you have a tear or episiotomy? *

Would you be interested in a Post-Natal Exercise Group? *

Is there anything else you would like your Physiotherapist to be aware of prior to your review? *

Does your child currently have NDIS funding? *

Is there pain associated with this problem? *

If yes, has the child had any other treatment for this problem? *

Is the child receiving any other services? *

If yes, please explain *

Are you aware of a group that you would like to try? *

Does this condition impact your ability to complete daily tasks, work, or provide care? *

Are you currently homeless or at risk of homelessness? *

Do you currently have a wound or ulcer on your foot that is not healing? *

If yes, do you have signs of spreading infection eg is it hot/red/swollen/heavy discharge *

Do you have Diabetes? *

Have you had a wound on your foot that took more than one month to heal? *

Have you had a toe, foot or leg amputated? *

If yes, why? *

Do you have any allergies we should be aware of? *

Relevant Medical History: *

Please list your current medications (if any): *

Have you had frequent presentations to hospital or a decline in health over past 6 months? *

Describe: *

Do you present a risk of falling? *

Have you had a fall within the last 6 months? *

Do you have issues with skin integrity? *

Have you recently lost weight without trying? *

Do you have issues with continence? *

Is there other identified risk factors or safety concerns? *

If yes, please describe: *

Are you recovering from recent surgery? *

Does your current situation impact on your safety or the safety of others? *

Is Family violence an issue? *

Are you having thoughts of suicide? *

Can you tell us briefly what the main issue is and how it is affecting your life? *

Why would you like to see the exercise physiologist? *

Have you had a broken bone or surgery for muscles or joints in the last 6 months? *

Have you been referred for a chest infection? *

Have you had a fall in the last 6 months? *

Would you be happy to attend a group session? *

Does your condition impact on your ability to care for people, complete daily tasks or work? *

If yes, please provide further detail: *

How long have you had this issue for? *

How severe is your pain? (please tick) *

Mild
Moderate
Severe

Have you been diagnosed with Diabetes? *

Yes
No

If yes, what type of Diabetes? *

Type 1
Type 2
Gestational
Pre-Diabetes

Are you newly diagnosed? *

Yes
No

Would you like to be referred for any of the below: *

What else would you like to referred for? *

Does this condition impact your ability to complete daily tasks, work or provide care? *

What part of your body is affected by the swelling? *

Do you currently have a wound or ulcer on the affected area? *

Are you currently homeless or at risk of homelessness? *

Do you have any allergies? *

Is this referral for an adult or a child? *

Is this referral for an adult or child? *

Are you willing to explore living well with pain and learn self- management strategies? (Please note: the purpose of this clinic is not to prescribe medication) *

Have you been discharged from a Public Hospital/ Emergency department in Victoria within the last 2 weeks?

Baby Number/Parity: *

Birth Type: *

Gestation…/40: *

Infant D.O.B: *

Infant Name: *

Birth Weight: *

History of breastfeeding?: *

Reason for referral: *

Further information about the reason for referral: *

Please list your current health conditions and other relevant medical history: *

Who is completing this form *

Name *

First

Last

Organisation (if applicable): *

Do you require follow up/contact?

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Is there anything else you need to tell us? *

Attachments- eg.test results, GP health summary, specialist reports etc

Click or drag a file to this area to upload.

Do you consent to us sharing your information with other health providers? (e.g- your local doctor) *

Yes
No

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