REFERRAL FORM
Bond University Allied Health (BUnyAH)
Interprofessional Healthy Lifestyle Program

For further information please contact reception on 07 5595 3500
Forward completed referral via Medical Objects: UB4226001CD

DATE: <FormattedDate> 
 PATIENT DETAILS 

RE: <PtFullName>	DOB: <PtDoB>	Gender:  <PtSex>	
Address: <PtAddress>
	Email: <PtEmail>	
Home Phone:  <PtPhoneH>	Work: <PtPhoneWk>	Mobile: <PtPhoneMob>	

REASON FOR REFERRAL

<Reason for referral>

PAST HISTORY

Has the patient previously attended a falls prevention or frailty program/clinic?    <Has patient previously attended a falls prevention/frailty program/clinic?>
If yes, please specify where and when: <If yes, please specify where and when>

Clinical History:  <PMHAll>

Investigations:  <Ix>

Medications:  <CurrentRx>

Allergies:  <Reactions>

Smoking:  <SmkStatus>  <SmkHx>

Alcohol:  <AlcHx>

Patient must meet ALL the following criteria to be eligible for the program:

• Age >65 or >55 (Aboriginal & Torres Strait Islander).
• Gold Coast resident living at home within the community (NOT RACH, NOT palliative).
• Score 1 or 2 in the FRAIL scale risk assessment.
• At risk of frailty - Presents with one or more of the following: social isolation, poor self-care, recent hospitalisation, polypharmacy, multimorbidity, falls, poor nutritional intake, low socio-economic, mood changes.
• Unable to access mainstream services (available privately, through private insurance and/or the medical benefit scheme).
• Has Commonwealth pension / health care card.
• Cognitively and physically able to provide informed consent and participate in group activities.
• A good understanding of English is essential, without the assistance of an interpreter.
<Patient meets ALL criteria listed in referral>	REFERRING GP/ORGANISATION DETAILS 
GP's Name: <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

ALTERNATIVELY, REFERRING ALLIED HEALTH PROFESSIONAL DETAILS (if this applies) **Please note that a GP sign-off is mandatory for this referral to be accepted**
AHP's name:  
Allied Health Profession:  
Organisation:  
Phone:  
Fax:  
Email:  	

The BUnyAH Interprofessional Healthy Lifestyles Program is supported by funding from Gold Coast Primary Health Network through the Australian Government's PHN Program. GCPHN is collecting your personal information for the purpose of assisting its activities and functions in the primary health care sector. Your contact details may be used to forward information and notifications from GCPHN. In some circumstances we may provide your information to our funding agency (Dept of Health and Aged Care) or to service providers that enter into legal contracts with us which are bound by confidentiality.  There is no legal requirement for you to provide your personal information, however if you chose not to disclose your personal information this may exclude you from our services and programs. We do not routinely disclose information overseas. For further information on how we manage your personal information see our website https://gcphn.org.au/privacy-policy 

FRAIL SCALE RISK ASSESSMENT
Patients must meet pre-fail criteria to be eligible for the BUnyAH program. Patients with a score of 3, may be accepted into the program after review by the BUnyAH staff to determine suitability.
	Questions	Scoring	Results	
Fatigue	Please ask the patient: How much of the time during the past 4 weeks did the patient feel tired?
A = All or most of the time
B = Some, a little or none of the time	A = 1
B = 0		
Resistance	Please ask the patient: In the last 4 weeks, by yourself and not using any aids, did you have any difficulty walking up 10 steps without resting?	Yes = 1
No = 0		
Ambulation	Please ask the patient: In the last 4 weeks, by yourself and not using aids,  did you have difficulty walking 300 metres OR one block?	Yes = 1
No = 0		
Illness	Does the patient have the following conditions?
•	Hypertension
•	Diabetes
•	Cancer (not a minor skin cancer)
•	Chronic lung disease
•	Heart attack
•	Congestive heart failure
•	Angina
•	Asthma
•	Arthritis
•	Kidney disease	0-4 answers = 0
5-11 answers = 1
(Please count the number of answers that apply prior to scoring)		
Loss of weight	Please ask the patient: Have you lost more than 5kg or 5% of body weight in the past year?	Yes = 1
No = 0		
	TOTAL SCORE			
	Scoring: Robust = 0    Pre-frail = 1-2    Frail = >3			
Eligible clients referred will undergo an initial and discharge assessment by allied health professionals in occupational therapy, physiotherapy, sports and exercise, psychology and dietetics. All students are directly supervised by a suitably registered clinician. BUnyAH provides a unique interprofessional and intergenerational approach to reducing frailty in the community, accompanied by a longer-term research strategy led by Bond University in partnership with Avanti Health Centres and the Gold Coast Primary Health Network. 
Each group program has a maximum of 20 participants. Programs will be provided from two sites: Site 1: Avanti Health Centre, Gold Coast Surgery Centre, Level 1, 103-113 Nerang Street, Southport, Site 2: Bond Institute of Health and Sport, 2 Promethean Way, Robina. Individual follow-up may be provided for both groups from Bond Institute of Health and Sport.