Grampians
Health	GH SMART Referral
Referral date: <FormattedDate>
Time of referral:<CurrentTime>	Version 10
(BP 6-2021)	

<AdrDetails>

REFERRED BY:
Name: <DrName>
Practice:<Practice>
Address:<UsrAddress>
Phone: <UsrPhone>
Fax:<UsrFax>
Provider #: <DrProviderNo>	PATIENT DETAILS:

Name:<PtFullName>
Gender:<PtSex>
DOB:<PtDoB>
Address:<PtAddress>
Home Ph:<PtPhoneH>
Mobile:<PtPhoneMob>
Medicare #:: <PtMCNo><PtMCLine>
Health fund: <PtInsFund>
Pension:<PtPensionNo>
DVA:<PtDVANo><PtDVACard>
ATSI:<PtEthnicity>
Interpreter required:<Interpreter required?>
Next of Kin: <NOKName><NOKRelation> <NOKContact><NOKContact2>
	
PATIENT CONSENT:

Patient consents to attend MBS bulk-billed clinic if available:<Patient consents to MBS bulk-billed clinic if avail?>
Indefinite referral? <Is this an indefinite referral?>
Patient consents to sharing medical information: <Patient consents to sharing of medical information>
	
SPECIALTY SERVICE:  <Specialist - MANDATORY>
	
REFERRAL DETAILS:

Referral type: <Referral type> 
GP Advised Priority:  <GP Advised Priority>
Previous referral for same condition: <Previous referral for same condition?>
Reasons for repeat referral: <If yes to above, reasons for repeat referral>
Are you the patient's usual GP:  <Are you the patient's usual GP?>
If not, name of usual GP: <If not, provide name of Usual GP & Practice>
	SPECIAL ALERTS:

Cancer status: <Cancer status for triage>
Positive FOBT: <Is this for positive FOB?>
NBCSP reference: <NBCSP ref# req & copy of results is required for triage>
Smoking status: <SmkStatus>
Alcohol history: <AlcHx> 
Any Disability: <Any disability?>	
ANTENATAL SHARED MATERNITY CARE: <Do you wish to participate in Antenatal Shared Care with BHS?>

CURRENT PREGNANCY: LMP: <LMP> EDC: <EDC><Gestation>
	
REASON FOR REFERRAL & PROVISIONAL DIAGNOSIS:

<Reason for referral/Provisional diagnosis>
	
BLOOD PRESSURE: <Current blood pressure> 
	WEIGHT: <Current weight>	
PROGRESS NOTES: 

<Visits>
	
ALLERGIES:

 <Reactions>
	
CURRENT MEDICATIONS: 

<CurrentRx>
	
PAST MEDICAL & SURGICAL HISTORY: 

<PMHAll>  
	
FAMILY & SOCIAL HISTORY: 

<FamilyHx> <SocialHx>
	
TESTS ORDERED TODAY?

<Tests today: Only tests attached to referral are viewable at triage>
	
NAME OF PATHOLOGY PROVIDER:    

<Name of Pathology Provider>   
	
NAME OF RADIOLOGY PROVIDER:

<Name of Radiology Provider>
	
INVESTIGATION RESULTS: 

<Ix>	

Electronically signed by:<DrName>