Western NSW Local Health District
HIGH RISK FOOT SERVICE GP REFERRAL FORM
Level 1, Macqaurie Building, Dubbo Base Hospital 
Phone: (02) 9113 1360   Fax: (02) 6809 7252  

(Please note that referral will NOT be accepted if form not filled out properly & required documents not attached) 
Name:	    <PtName>	D.O.B:	   <PtDoB> 	  Sex:  <PtSex>	
Address:	   <PtAddress>	
Telephone:	(H)   <PtPhoneH>	(W)   <PtPhoneWk>        (M)  <PtPhoneMob>	
Does patient require an interpreter	   <Does pt require an interpreter>	Preferred Language spoken: <PtLanguage Preferred>          <PtLanguage Spoken>	
DVA Gold Card holder	   <PtDVANo>	Aboriginal or Torres Strait Islander	   <PtEthnicity>	
NOK:    <NOKName>	Contact details:  <NOKContact>	

TO QUALIFY FOR THE HRFS PATIENTS MUST HAVE ONE CONDITION FROM EACH SECTION (A + B):

SECTION A

<PT. must have one of the following in section A.>	Patients must have one of the following medical conditions: 	

  Diabetes <Diabetes?>
Insulin Dependent: <Insulin Dependent?>
HBA1c: <Patients HBA1c?>	
  <Rhuematoid Arthritis with deformity?>  Rheumatoid Arthritis with
deformity - 	
 <Renal Failure - chronic or dialysis?>  Renal failure- chronic or dialysis  - 	

  <Peripheral Neuropathy?>   Peripheral Neuropathy  - 	
  <Significant PVD>   Siificant PVD  	
  <Previous Amputation?>  Previous  amputation  	

  <Previous/Current ulceration??>  Previous/Current ulceration  	
Diagnoses / Comments:  <Diagnoses / Comments:>	

Section B

<Pt must have one of the following in section B>		  <Foot Ulcer not reducing after 4 weeks> Foot ulcer not reducing in size after 4 weeks of appropriate treatment   	

 <Deep foot ulcer (probes to tendon, joint & bone) ?> Deep foot ulcer (probes to tendon, joint or bone)	

 <Foot ulcer associated withan absence of foot pulse>Foot ulcer associated with an absence of foot pulses	

 <Infected Foot Ulcer?>  Infected foot ulcer	

 <Suspected Charcot's Neuroarthropathy?>  Suspected Charcot’s Neuroarthropathy	

 <Chronic Charcot's Neuroarthropathy?>  Chronic Charcot’s Neuroarthropathy	

  <Cellulitis?>  Cellulitis	

Please mark the area where the presenting complaint occurs:
	 
Options Already Pursued:	
•	Dressing Regime: 	
•	Offloading:	
•	Antibiotic Therapy:	
•	Other:	

Investigation Results – Please attach copies of all relevant results	
•	X-ray	•	Blood Test including ESR and HbA1c	•	Wound biopsy	
•	Wound Swab	•	Bone Scan	•	MRI	
Other Clincial Infotmation: Please attach copies of full medical history and current medication list:	
•	Medical History
       <PMHActive>
•	Medication List
     <SelectedRx>
•	Allergies: 
     <Reactions>         
Weight    <Patient Weight>KG                                                                                                  	
Previously S/B Diabetes Educator      <Previously S/B Diabetes Educator?>
Date: <Date Pt seen Diabetes Educator?>	 Previously S/B Dietitian:   <Previously S/B Dietitian?>  
 Date: <Date Pt seen Dietitian?>	Previously S/B Social Worker:  <Previously S/B Social Worker?>  
Date:  <Date previously seen Social Worker>	
•	Known intellectual disability: 
<Any know intellectual Disability?>	•	Known mental illness:   
<Any know mental illnesses?>	•	Other: 
<Other:>	
Referring Doctors Details 
Doctors Name: <DrName>
Doctors Provider Number: <DrProviderNo>
Practice Address: <UsrAddress>
Practice Phone: <UsrPhone>

Doctors Signature:  					                   Date:  <TodaysDate>

PLEASE ARGUS to Dubbo Health Service Ambulatory Care - High Risk Foot Clinic: WNSWLHD-ccdubcapac@health.nsw.gov.au
or 
FAX REFERRALS TO 02 6809 7252