REQUEST FOR CONSULTATION
COMPLEX WOUND CLINIC
BUNDALL MEDICAL CENTRE
Referral for assessment of patient for wound care

SEND TO Dr Stephen Yelland (General Practitioner)
Complex Wound Clinic
Bundall Medical Centre
21 Ashmore Road
Bundall

Secure Transmission Service via Medical Objects to:
Dr Stephen Yelland 352395B	From Treating Doctor.Name
Practice.Name
Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Email: Treating Doctor.E-mail
Provider Number: Treating Doctor.Provider Number

                  

Miscellaneous.Date

Dear Dr Yelland

SECTION 1 Patient details

RE: Patient Demographics.Full Name
DOB: Patient Demographics.DOB
AGE: Patient Demographics.Age

Gender: Patient Demographics.Gender
Address: Patient Demographics.Address
Home Ph: Patient Demographics.Phone (Home)
Mobile Ph: Patient Demographics.Phone (Mobile)
Medicare Number*: Patient Demographics.Medicare Number  (*Medicare ineligible patients will incur a consultation fee)	Next of Kin/Alternative Contact: Patient Demographics.NOK Name
Next of Kin/Alternative Contact Ph: Patient Demographics.NOK Mobile Phone
Does the patient identify as Aboriginal and/or Torres Strait Islander: Does the pt identify
Interpreter required: Interpreter required
If yes, specify language: If yes, specify lang	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: Specify main reason 

Please provide provisional diagnosis (if available): Provisional diagnosi

Please provide history of wound (if known): Wound history

Please provide date of onset if known:  Date of onset

Please include details of treatment regime so far: Treatment Regime

Has any compression therapy been used: Compression Therapy

If compression therapy has been used, what type: Type of comp therapy

Please provide relevant information
Clinical examination findings: Clinical examination

List any other members of management team, eg Specialists, Podiatrists, Domiciliary Nursing: Management team

Please provide details of any in patient or outpatient care to date: Inpatient/outpatient

SECTION 3 Mandatory clinical information

Please include patient health summary and/or a copy of the GPMP and TCA containing this information. (This will allow the Wound Clinic to contribute to the patient's Care Plan)

Information to include:

Current and past medical history:

Clinical Details.Problem List (Current) With Comments

Clinical Details.Problem List (Resolved) With Comments

Alcohol: Clinical Details.Alcohol

Smoking: Clinical Details.Smoking

Allergies: Clinical Details.Allergies

Current prescribed medications: Clinical Details.Medications - Current Regular

SECTION 4 Investigations

Please indicate whether the following investigations have been undertaken and attach the results. In addition, please also attach any investigation results you consider to be relevant..

Please include the following results if available:
FBC, E/LFTs, ABI, Imaging, Arterial/Venous duplex scans, Biopsy, Microbiology:

Clinical Details.Result List (Selected)

SECTION 4 Social factors and impact on the patient

Consider the impact on employment/education; activities of daily life; ability to care for others; personal safety/frailty; other factors. Please paste or type relevant information.