Townsville General Practice Network

Forms, Glorious Forms!

Every GP likes to be surrounded by forms. Here are some you may have missed:

AGED CARE

• ACAT Form: [PDF format] or [DOC format]
• Older Person's mental health referral form [DOC format] or [PDF format]
• Comprehensive Medical Assessment for Nursing Home Residents as a pdf or as a Word (doc) template

ATAPS

• ATAPS - Understanding the Eligibility Criteria and Referral Process
• K10
• EPDS
• GP Mental Health Care Plan
• ATAPS Referral Form (DOC or PDF or RTF)

For information on ATAPS Clinicians click here

CASE CONFERENCING

• Case conference template, TGPN [DOC format]
• Case Conference Summary form (adapted from RACGP proforma) [DOC format]
• IHCP Record of Case Conference GP participating 795_742_765
• IHCP Record of Conference GP organising  740_742_744
• IHCP Record of Case Conference GP contributing to multidisciplinary care plan 729

CHILD HEALTH

• Child Abuse Notification (TGPN) [PDF format] or [DOC format]
• Child Abuse Notification - AHGP
• [For information about Child Abuse reporting see Child Health page.]
• Child and Youth Mental Health Referral form [DOC format].
• Paediatric Allied Health Form: [PDF format] or [DOC format]

CHRONIC DISEASE MANAGEMENT

• Asthma Action plans. Templates available from NACA, from various organisations. Some suitable for Asthma Cycle of Care
• Monash Division of General Practice has several templates available
• Chronic Disease Management Interactive
  Templates from ADGP. Includes GP Management Plan and Team Care Arrangements [for MD only]
• Chronic Disease management Forms: Federal Govt Versions Including GP Management Plan and Team Care Arrangements
• EPC Allied Health Referral Form: [PDF format]
• Referral Form for Dental Services under Medicare: [PDF Format]
• GP Management Plan & Reviews (Instruction to Import Template into Medical Director)

DIABETES

• Diabetes Management Cycle of Care template Easily adapted for MD, Spectrum Classic or Practix
• Diabetes Management Review Sheet Useful aid to completing an Annual Cycle of Care. Easily adapted for MD, Spectrum Classic or Practix
• Diabetes Tracking Record
• MSS Form
• MD Form
• CDM Management Tool
• Referral Form - For Allied Health Group Services Under Medicare

Group Services for Type 2 Diabetes

Fact Sheet for GPs
Fact Sheet for Allied Health Professionals
Allied Health Group Serviecs Referral form

DRUGS AND ALCOHOL

• Alcohol, Tobacco & Drug Referral Form: [PDF format] or [DOC format]
• Drugs of Dependence Report Form: [PDF format] or [DOC format]
• Alcohol Screen (AUDIT)

GENERAL

• Medicare Forms (1)
• Medicare Forms (2)
• Department of Veteran Affairs Forms
• Medical Certificate for Driver’s Licence
• RACGP New Patient Form: [PDF format]
• Cremation Form 2: [PDF format] or [DOC format]
• Patient Travel Subsidy Scheme Application Form
• Forms for Disabled Parking Permits
• The book on Assessing Fitness to Drive
• Taxi Subsidy Scheme Application form

HEADSPACE

• GP Referral Form
• Non-GP Referral Form

HEALTH Assessments - 45 year old

• SCDGP Template for 45 yo Health Check [RTF format, with Medical Director template fields]
• NEVDGP Template and Tips for 45 yo Health Check [RTF format, with Medical Director template fields]

HEALTH Assessments - 75 year old
(also for Indigenous people 55 and over)

• MD template
• RACGP version with no merge fields
• Mini-Mental State Examination

HEALTH Assessments - Intellectual Disability

• [RTF format, with Medical Director template fields] Template for Item 718, Health Assessment for a patient with an intellectual disability
. An experienced person may be able to convert this for use in other Practice Management Systems

HEARING

• Australian Hearing Services. This website provides referral forms, voucher applications and other information for GPs and members of the public

INDIGENOUS HEALTH

• ATSI Adult Health Check (Item 710) template RTF format for Medical Director from the Southern Division of General Practice (SA). Depending on practice expertise, it may be possible to adapt this for other Practice Managment Systems
• ATSI Child Health Check (Item 708) template RTF format for Medical Director from the Southern Division of General Practice (SA). Depending on practice expertise, it may be possible to adapt this for other Practice Managment Systems


See also the section above, Health Assessments

Integrated Health Care Partnership (IHCP)

MATERNITY / CHILD BIRTH / PERINATAL

• Alcohol and Drugs and Tobacco Screening Tools
• Edinburgh Postnatal Depression Scale
• Safe Start
• Townsville Birth Centre Eligibility Checklist

MENTAL HEALTH

• Rapid Assessment Form.[DOC format] or [PDF format]
• Integrated Mental Health Form: [PDF format] or [DOC format]
• Mini-Mental State Examination
• Brief Guide to the Mental Health Act
• Request for Mental Health Assessment
• Recommendation for Mental Health Assessment
• Request for Police Assistance
• GP Mental Health Management Plan [DOT format]
. All referrals to the CATT team please complete this form and attach a cover letter then fax to CATT on (07) 4799 9506
• OzCare Mental Health Program referral form [PDF format]
• Older Person's mental health referral form [DOC format] or [PDF format]
• Kessler Psychological Distress Scale (K10) [PDF format]
• Early Intervention Specialists (Child, Youth and Family Health Services Townsville) Eligibility Criteria for Referral to Early Intervention Specialists, and Referral form to Early Intervention Specialists

PAIN MANAGEMENT

• Pain Clinic Referral Form: [PDF format] or [DOC format]
• Pain Clinic Management Plan Overview: [PDF format] or [DOC format]

PALLIATIVE CARE

• Interim Medication Order for Symptom Control at the End of Life [DOC Format] or [PDF Format]
• Palliative Care Multidisciplinary Meeting [DOC format] or [PDF format]
• Palliative Care Referral Form (TTH) [DOC format]

REFERRALS

• ACAT Form: [PDF format] or [DOC format]
• Advance Employment Referral Form [PDF Format]
• Alcohol, Tobacco & Drug Referral Form: [PDF format] or [DOC format]
• Cardiac Rehabilitation Outpatient Programreferral form [DOC format]
• EPC Allied Health Referral Form: [PDF format]
  
• Family Care Program Form: [PDF format] or [DOC format]
• Guide Dogs Queensland referral here
  
• JCU Physio Clinic Referral Form: [PDF format]or [DOC format]
• Meals on Wheels Referral Form: [PDF format] or [DOC format]
• Neurophysiology Referral Form: [PDF format]
• Paediatric Referral Form: [PDF format] or [DOC format]
• Queensland Hearing Loss Family Support Service Referral Form: [DOC format]
• Qld Clinical Genetics Service Referral form: [PDF format] or [DOC format]
• Referral to Integrated Health Care Partnership: [DOC format]
• Surgical Referral or [Doc template] for Practix / Plexus

Click here to go the referral Forms Page

REFUGEE ASSESSMENTS

• Refugee Health Assessment Template (12-Dec-07)
• Refugee Health Assessment Training Book

• MD Template Instructions

RESUSCITATION PLAN

• Resuscitation Plan (Read Only)

WORKERS COMPENSATION

• Workcover Queensland Hospitalisation Request form
• Workcover Certificate site
• www.workcoverqld.com.au
• www.qcomp.com.au

An electronic version of the medical certificate is available by phoning 1300 361 235.

Some of the above documents require the use of the Adobe Reader, free software available from adobe.com

Page last modified: 11 Aug 2010

 
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