Western NSW Local Health District
HIGH RISK FOOT SERVICE GP REFERRAL FORM
Level 1, Macquarie 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:	    <<Patient Demographics:Full Name>>	D.O.B:	   <<Patient Demographics:DOB>>	Sex:  <<Patient Demographics:Gender>>	
Address:	   <<Patient Demographics:Full Address>>	
Telephone:	(H)   <<Patient Demographics:Phone (Home)>>	(W)   <<Patient Demographics:Phone (Work)>> (M)  <<Patient Demographics:Phone (Mobile)>>	
Does patient require an interpreter	   <<Does pt require an interpreter>>	Preferred Language spoken: <<Patient Demographics:Language Preferred>>          <<Patient Demographics:Language Spoken>>	
DVA Gold Card holder	   <<Patient Demographics:DVA Number>>	Aboriginal or Torres Strait Islander	   <<Patient Demographics:Ethnicity>>	
NOK:    <<Next of Kin?>>	Contact details:  <<NOK contact details?>>	

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  -  <<Does Patient have Diabetes?>>
Insulin Dependent: <<Insulin Dependent ?>> 
HBA1c:  <<What's patients HBA1c?>>	
 Rheumatoid Arthritis with
deformity - <<Rhuematoid Arthritis with deformity?>>	
 Renal failure- chronic or dialysis  - <<Renal Failure - chronic or dialysis?>>	

 Peripheral Neuropathy  - <<Peripheral Neuropathy?>>	
  Significant PVD  <<Significant 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 in size after 4 weeks of appropriate treatment   	
<<Foot Ulcer not reducing after 4 weeks>>	

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

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

 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 Clinical Information: Please attach copies of full medical hisotry & current medication list		
•	Medical History 
•	<<Clinical Details:History List>>

•	Weight:   <<Patient Weight?>>kg	•	Medication List
<<Clinical Details:Medication List>>
•	Allergies: 
<<Clinical Details:Allergies/Adverse Reactions>>                                                                                                              	
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: <<Doctor:Name>>
Doctors Provider Number: <<Doctor:Provider Number>>
Practice Address: <<Practice:Address>>
Practice Phone: <<Practice:Phone>>

Doctors Signature:  					                   Date:  <<Miscellaneous:Date>>

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

Argus: Patient Name: <<Patient Demographics:Full Name>>    DOB: <<Patient Demographics:DOB>>   Address:<<Patient Demographics:Address>>