Please Complete & Fax to TTH on 4433 2810, ALONG with the Following

Referral Form - ORTHOPAEDICS

Patient Name: / Patient UR:
Patient Address: / Patient D.O.B:
Patient Phone: / Patient mobile:
Referring Doctor:
Specialists: ý Dr Rhys Edwards (Default if no selection) Dr Kaushik Hazratwala Dr Peter McEwen
Dr Matthew Wilkinson Dr Ashish Gupta Dr Bruce Low Dr David Ness
Any of the selected specialists or their nominated locum
Interpreter required? Y / N Language (please specify): ______
Provisional Diagnosis: / Fitness For Surgery - American Society of Anaesthesiologists (ASA) physical status classification
I. / Healthy patient
II. / Mild systemic disease with no functional limitation - for example, controlled hypertension
Pre-Requisite Tests Completed / Yes / No / III. / Severe systemic disease with definite functional limitation - for example, chronic obstructive pulmonary disease
Reason for Referral: / IV. / Severe systemic disease that is a constant threat to life - for example, unstable angina
Duration of Symptoms: / Conservative Managements Trialled
Medications
Red Flag Symptoms and Signs: / Episodic simple analgesics / Narcotics
Regular paracetamol / Regular NSAI
Constant pain / Steroid injections
Unexplained
weight loss / Worsening neurological
symptoms / Allied Health
Walking Distance: / Systemic illness & fever / Physiotherapy / N/A Sessional only
Full Trial (> than 6 weeks)
Functional Deficits due to condition / In Mtrs / Orthotics/Splints / Yes No N/A
Dietician & Weight reduction / Yes No N/A
Work / Other / Yes No N/A
Work
Activities
Daily
Living / Mild/Moderate
Significant
Unable to perform
Nil or N/A
Plain Xray
Activities
Daily
Living
Night Pain affecting Sleep / Mild/Moderate
Significant
Unable to perform
Nil or N/A / CT
Night Pain affecting Sleep
Recreation / Occasional
Moderate
Significant
Nil or N/A / Ultrasound
Recreation
Sex / Mild/Moderate
Significant
Unable to perform
Nil or N/A / MRI
Nerve Conduction Studies
Other
GP Signed:
Date:

Please complete & fax to TTH on 4433 2810, ALONG WITH the following:

1.Referral letter 2. ALL RESULTS

Refer EMERGENCY conditions to the ED. & Telephone ED Registrar, ph. 4433 2916 (Version: Nov 2013)

Referral Form - ORTHOPAEDICS

Please complete & fax to TTH on 4433 2810, ALONG WITH the following:

1.Referral letter 2. ALL RESULTS

Refer EMERGENCY conditions to the ED. & Telephone ED Registrar, ph. 4433 2916 (Version: Nov 2013)