Western NSW Local Health District
Geriatric Medicine Clinic Referral
To: Western NSW LHD Geriatric Medicine Services: 
Argus email: WNSWLHD-accescenagedcare@health.nsw.gov.au 
or 
Upload Referral (using link https://www.agedcarewnsw.com.au/AgedCare/  -  
Referrals for Geriatric Medicine and Complex Aged Care Needs or fax 02 6841 2676) 

Date: <FormattedDate>

Doctors Name: 	
Dr John Cullen
Dr William Thoo
Dr Jennifer McMeniman
Dr Robyn McCarthy
Dr Cameron Kord-Wells
Dr Agnes Kainer
Dr Catriona Ireland - Orange 

GP Referrer Details: 
<DrDetails>

Who has requested this referral? <Who has requested this referral?>

Patient's Details:
<PtDetails>
Mob: <PtPhoneMob>     Home: <PtPhoneH>
DOB: <PtDoB>
Medicare Card: <PtMCNo>    Line no:  <PtMCLine>    Exp: <PtMCExpiry>

Martial Status:     <PtMaritalSt>
Aboriginal / Torres Strait Islander?     <PtEthnicity>
Country of Birth?      <Country of Birth?>			       

Person Responsible /Carer: 
<NOKName>
<NOKRelation>
<NOKContact>

Carer?  <Is your Next of Kin your Carer?>

Reason for Referral (please provide significant details about why you are making this referral:
<Reason for Referral? (Provide significant details)>

SUPPORTING DOCUMENTS
Please copy & paste any other accompanying documents to bottom of this referral which may enchance this referral. e.g. GPMP/ TCA or Health Summary etc. 

Screening for Geriatric Medicine

Impaired Cognition Screen: <IMPAIRED COGNITION SCREEN>
Routine: 

Yes or No		
<FBC,ESR,Electrolytes, renal fx,total protein, LFT's?>	FBC, ESR, Electrolytes, renal functions, total protein, LFT's, 	
<Calcium, Magnesium,Phosphate,Random Glucose?>	Calcium, Magnesium, Phosphate, Random Glucose	
<FTFTs?>	TFTs	
<B12/Folate?>	B12/Folate	
<Syphillis serology?>	Syphillis serology	
<U/A with MSU if abnormal?>	U/A with MSU if abnormal	
<Brain CT?>	Brain CT	
<CXR>	CXR	

Atypical Presentation with Risk Factors: <ATYPICAL PRESENTATION WITH Risk Factors>
<HIV Serology?>	HIV Serology	
<Various immunology tests>	Various immunology tests	

Continence: <Continence>
<U/A - MSU>	U/A - MSU	
<Glucose?>	Glucose	
<Electrolytes and renal function>	Electrolytes and renal function	
<Calcium/Magnesium/Phosphate/Albumin>	Calcium/Magnesium/Phosphate/Albumin	

Nutrition/Weight Loss: <NUTRITION / WEIGHT LOSS>
<Weight/BMI>	Weight/BMI	
<Electrolytes, Renal Fx, Albumin,Total Protein,LFTs?>	Electrolytes, Renal Fx, Albumin, Total Protein, LFTs	
<Calcium,Magnesium,Phosphate, Random Glucose?>	Calcium, Magnesium, Phosphate, Random Glucose	
<FBC?>	FBC	
<Coags?>	Coags	
<B12/Folate/Iron Studies/ 250H Vit D?>	B12/Folate/Iron Studies/ 250H Vit D	
<CXR?>	CXR	

Low impact Fractures: <LOW IMPACT FRACTURES?>
<FBC, CRP?>	FBC, CRP	
<Electrolytes, Renal fx, Albumin,Total protein, LFTs?>	Electrolytes Renal functions, Albumin, Total protein, LFTs	
<Calcium,Magnesium,Phosphate,Random Glucose?>	Calcium, Magnesium, Phosphate, Random Glucose	
<TFTs?>	TFTs	
<250H Vit D, PTH?>	250H Vit D, PTH	
<Serum/Urine EPG?>	Serum/Urine EPG	

Acknowledgement: Aged Care Service Parkes/Concord Geriatric Services 2010
Update  July 2017 - V_110417