04/09/2010
Referral Form
Patient Details
*Mandatory Fields
Hospice Service referred To:
Far North
Hospice Mid-Northland
Kaipara pc
North Haven
Please Select
*
NHI Number:
Please enter in this Format Ex NHN2345
Referral Date: (Please enter Date in dd/mm/yyyy format)
(DD/MM/YYYY)
*
Title:
Mr.
Mrs.
Ms.
Dr.
Prof.
Miss.
Master.
Rev.
Please Select
*
FamilyName:
*
First Name:
*
Preferred Name:
Second Name:
Third Name:
Address line 1:
*
Address Line 2:
Suburb:
City/Town:
*
Country/Region:
Please Select
BOI
Far North
Kaipara
Whangarei
Other
Domicile:
Please Select
Email:
Home Phone:
*
Mobile:
Alternative Phone Number:
Fax:
DOB: (Please enter Date in dd/mm/yyyy format)
(DD/MM/YYYY)
Ethnic Group:
European not further defined
NZ European / Pakeha
Other European
Maori
Pacific Island not further defined
Samoan
Cook Island Maori
Tongan
Niuean
Tokelauan
Fijian
Other Pacific
Asian not further defined
South East Asian
Chinese
Indian
Other Asian
Middle Eastern
Latin American / Hispanic
African
Other
Not Stated
Please Select
Gender:
Male
Female
Indeterminate
Not stated/inadequately described
Please Select
Country of Birth:
Afghanistan
Africa Undefined
Albania
Algeria
America(USA only)
America Undefined
America Samoa
Andorra
Angola Republic of
Anguilla
Antartic Regions Foreign
Antartic Stations British
Antartic Stations USA
Antartica Undefined
Antigua and Barbuda
Argentina
Armenia
Aruba
Asia Undefined
Australia
Austria
Azerbaijan
Bahamas
Baharain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Born at sea
Bosnia - Herzegovina
Botswana
Brazil
British Indian Ocean teritory
Brunei Darussalam
Bulgaria
Burkina Faso
Burma(Myanmar)
Burundi
cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African RePublic
Chad
Channel Islands
Chile
China, Peoples Republic of
Christmas Islands
Cocos (keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d Ivorie
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East timor
Ecuador
Egypt
El Salvador
England
Equatorial guinea
Eriteria
Estonia
Ethiopia
Europe
Faeroe Islands
Falkland Islands
Fiji
Finland
France
French Guinea
French Polynesia
French Southern Teritories
Gabon
Gambia
Georgia
Germany
Germany Undefined
Ghana
Gibraltar
Great Britian
Greece
Green Land
Grenada
Guadeloupe
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Hounduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland Undefined
Ireland , Republic of (Eire)
Isle of Man
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kirbati
Korea , Democratic Peoples of Republic of (North)
Korea, Republic of south
Kuwait
Kyrgystan
Laos
Lativia
Lebanon
Leothso
Liberia
Libyan Arab Republic
Liechtenstein
Lithunia
Luxembourg
Macao
Macedonia, Former Yougoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Melenisia Undefined
Mexico
Micronesia Undefined
Micronesia, Feferated States of
Moldova
Monaco
Mongolia
Montserrat
Morroco
Mozambique
Myanmar(Burma)
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicargua
Niger
Nigeria
Niue Island
Norfolk Island
Northern Ireland
Northern Mariana Islands
Norway
Oman
Pacific Islands Undefined
Pakistan
Palau
Panama
Papua New guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Polynesia undefined
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
San Marino
Sao tome Principe
Saudi Arabia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovania
Solomon Islands
Somalia
South Africa
South America Undefined
South East Asia Undefined
South Georgia and the South Sandwitch Islands
Spain
Sri Lanka
St Helena
St Kettis Nevis
St Lucia
St Pierre Miquelon
St Vincent and the Grenandines
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands , United States
Wales
Wallis and Futuna Islands
Yugoslavia
Zaire
Zambia
Zimbabwe
Samoa, Western
Please Select
NZ Residency:
Yes
No
Occupation:
Specific Cultural Needs:
Language Spoken:
Patient Lives with:
Please select
Lives alone
Lives with either spouse/ partner and other family
Lives with other family members
Lives with other members of the community
Lives with spouse/ partner
Not stated/ inadequately described
Other arrangements
Interpreter Required:
Yes
No
Please Select
Community Services Card:
Yes
No
Please Select
Insurance Status:
Private Health Insurance:
Diagnosis Type:
Malignant
Non-Malignant
Please Select
Diagnosis/Operation/Accident Description:
Diagnosis Date: (Please select Month and enter year in yyyy format)
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Allergies/ Sensitivities:
Current Issues:
Relevant Social History:
Reason For Referral:
Symptom Control
Respite Care
Counselling
End Stage Care
Is Advanced Care Plan:
In Place
Discussed
Not Discussed
Not Applicable
Please Select
Other Services Involved:
District Nurses
OT
Social Worker
Iwi Provider
Physio
Home Support
Cancer Society
Oncology
Other
Iwi:
Carer Support:
Please Select
Yes
No
Patient Aware of Referral:
Please Select
Yes
No
Patient Aware of Diagnosis:
Please Select
Yes
No
Insight into Prognosis:
None
Realistic Insight
Some Insight
Please Select
Referrer Details
Referrer Name:
*
Referral Source:
Family
Hospital and Health Services
Rest Home/Hospital
Cancer Society
Maori Health Provider
Community Support agency
General Practitioner
Palliative Care Service
Other
Oncologist
District nurse
Please Select
*
Auckland DHB
Waitamata DHB
Northland DHB
Other DHB
Private Hospital
Phone:
*
Fax:
Date of Admission: (Please enter Date in dd/mm/yyyy format)
(If Referring Agency - Hospital)
(dd/mm/yyyy)
Department:
(If Referring Agency - Hospital)
Surgical
Medical
Oncology
Paediatric
Other
Please Select
GP Details
Select GP
Title:
Mr.
Mrs.
Ms.
Dr.
Prof.
Miss.
Master.
Rev.
Please Select
Surname:
Given Name:
Clinic Name:
Address:
Suburb:
City/Town:
Post Code:
Phone:
Fax:
Email:
I am willing to participate in multi disciplinary care plans and case conferences:
Please Select
Yes
No
Specialist Details
Select a Specialist
Title:
Mr.
Mrs.
Ms.
Dr.
Prof.
Miss.
Master.
Rev.
Please Select
Surname:
Given Name:
Position:
Hospital/Clinic Name:
Address:
Suburb:
City/Town:
Post Code:
Phone:
Fax:
Email:
Primary Carer Details
Primary Carer Available:
Yes
No
Title:
Mr.
Mrs.
Ms.
Dr.
Prof.
Miss.
Master.
Rev.
Please Select
Surname:
Given Name:
Address1:
Address2:
Suburb:
City/Town:
Post Code:
Phone:
Mobile:
Email:
Relationship:
© 2007 PalCare. All rights reserved.
PalCare designed and developed by eClinic Pty Ltd.