Grampians
Health	GH SMART Referral Template
Referral date: Miscellaneous.Date
Time of Referral: Miscellaneous.Time	Version 10
( 06-2021 ZM)	

REFERRED BY:

Name: Treating Doctor.Name
Practice: Practice.Name
Address: Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Provider #: Treating Doctor.Provider Number
Date:Miscellaneous.Date

	PATIENT DETAILS:

Name: Patient Demographics.Full Name
Gender: Patient Demographics.Gender
DOB: Patient Demographics.DOB
Address: Patient Demographics.Address Patient Demographics.Suburb
Home ph: Patient Demographics.Phone (Home)
Mobile: Patient Demographics.Phone (Mobile)
Medicare #: Patient Demographics.Medicare Number
Health fund: Patient Demographics.Health Fund Name
Patient Demographics.Health Fund Member Number
Pension:Patient Demographics.Pension Number
DVA #: Patient Demographics.DVA Number
Patient Demographics.DVA Expiry Date
ATSI: ATSI
Interpreter required: Interpreter2 
Next of kin:Patient Demographics.NOK Name 
Patient Demographics.NOK Relationship
Patient Demographics.NOK Home Phone 
Patient Demographics.NOK Mobile Phone	
PATIENT CONSENT:

Patient consents to attend MBS bulk billed clinic if available: mbs
Do you wish this to be an indefinite referral? Indefinite referral
Patient consents to sharing medical information: Consent
	
SPECIALTY SERVICE: specialist
	
REFERRAL DETAILS:

Referral type: Referral type
GP Advised Priority: Urgency
Reasons for repeat referral/change in condition: reasons
Are you the patient's usual GP: UsualGP
If not, name of usual GP:Name of Usual GP
	SPECIAL ALERTS:

Cancer status: Cancer
Positive FOBT: Positive FOBT
NBCSP reference number: NBCSP/Path reference
Smoking status: Clinical Details.Smoking
Any disability: Any disability
Any other disability?: Any other disability
	
ANTENATAL SHARED MATERNITY CARE: Antenatal

CURRENT PREGNANCY: Pregnancy.Current Gestational DatesPregnancy.EDC
	
REASON FOR REFERRAL & PROVISIONAL DIAGNOSIS:

History 
	
BLOOD PRESSURE: Blood pressure	WEIGHT: weight
	
PROGRESS NOTES: 

Clinical Details.Selectable Encounter Notes 
	
ALLERGIES/ADVERSE REACTIONS:

Clinical Details.Allergies	
CURRENT MEDICATION:

Clinical Details.Medication List
	
PAST MEDICAL & SURGICAL HISTORY:

Clinical Details.Problem List (Current)
Clinical Details.Problem List (Resolved)
	
FAMILY & SOCIAL HISTORY:

Clinical Details.Social History
Clinical Details.Family History
Clinical Details.Alcohol
	
TESTS ORDERED TODAY:

Tests ordered today
	
NAME OF PATHOLOGY PROVIDER:  

 Pathology Provider   
	
NAME OF RADIOLOGY PROVIDER:

Radiology Provider
	
 INVESTIGATION RESULTS:

Clinical Details.Result List (Selected)

Electronically signed by:Treating Doctor.Name