Taranaki Referral Form
Taranaki Extended Care team referral form
Please tick to confirm your patient meets the following eligibility criteria for referral to Taranaki Extended Care Team:
*
Diagnosed with a long term condition e.g. DM Type 2, CHF, CVD, COPD
Aged over 15 years
Identified as high risk of developing a long term condition ie IGT/pre-diabetes
Not currently under care of secondary care allied health
Eligible for publicly funded care in New Zealand
And any of the following:
*
Medication management concerns e.g. polypharmacy, multiple prescribers, non-adherence
Identified nutritional concerns e.g. elevated or significantly lowered BMI
Identified as having difficulties self-caring/ self-managing
Identified concerns regarding lifestyle/environment/ support
Identified concerns regarding communication/memory/disengagement with health services
Referral Detail
Date:
*
Name:
*
Phone(day time):
Phone(after hours):
Address:
*
Mobile:
Postcode:
*
NHI:
Date of Birth:
*
Gender:
*
Male
Female
Ethnicity:
*
--Select--
European nfd
Other European
Maori - NZ
Pacific Peoples nfd
Samoan
Cook Islands Maori
Tongan
Niuean
Tokelauan
Fijian
Other Pacific Peoples
Asian nfd
Southeast Asian
Chinese
Indian
Other Asian
Middle Eastern
African
Other Ethnicity
Don't Know
Refused to Answer
Response Unidentifiable
Not Stated
Repeated Value
Response Outside Scope
New Zealand European
European nfd
New Zealand European
British nfd
Celtic nfd
Channel Islander
Cornish
English
Gaelic
Irish
Manx
Orkney Islander
Scottish
Shetland Islander
Welsh
British nec
Dutch
Greek
Polish
South Slav nfd
Croatian
Dalmatian
Macedonian
Serbian
Slovenian
Bosnian
South Slav nec
Italian
German
Australian
Albanian
Armenian
Austrian
Belgian
Bulgarian
Belorussian
Corsican
Cypriot nfd
Czech
Danish
Estonian
Finnish
Flemish
French
Greenlander
Hungarian
Icelandic
Latvian
Lithuanian
Maltese
Norwegian
Portuguese
Romanian
Gypsy
Russian
Sardinian
Slavic
Slovak
Spanish
Swedish
Swiss
Ukrainian
American
Burgher
Canadian
Falkland Islander
New Caledonian
South African nec
Afrikaner
Zimbabwean
European nec
Maori
Pacific Peoples nfd
Samoan
Cook Islands Maori nfd
Aitutaki Islander
Atiu Islander
Mangaia Islander
Manihiki Islander
Mauke Islander
Mitiaro Islander
Palmerston Islander
Penrhyn Islander
Pukapuka Islander
Rakahanga Islander
Rarotongan
Tongan
Niuean
Tokelauan
Fijian
Admiralty Islander
Australian Aboriginal
Austral Islander
Palau Islander
Bismark Archipelagoan
Bougainvillean
Caroline Islander
Easter Islander
Gambier Islander
Guadalcanalian
Chamorro
Hawaiian
Kanak
Kiribati
Malaitian
Manus Islander
Marianas Islander
Marquesas Islander
Marshall Islander
Nauruan
New Britain Islander
New Georgian
New Irelander
Banaban
Papua New Guinean
Phoenix Islander
Pitcairn Islander
Rotuman
Santa Cruz Islander
Tahitian
Solomon Islander
Torres Strait Islander
Tuamotu Islander
Tuvaluan
Ni Vanuatu
Wake Islander
Wallis Islander
Yap Islander
Pacific Peoples nec
Asian nfd
Southeast Asian nfd
Filipino
Cambodian
Vietnamese
Burmese
Indonesian
Laotian
Malay
Thai
Southeast Asian nec
Chinese nfd
Hong Kong Chinese
Cambodian Chinese
Malaysian Chinese
Singaporean Chinese
Vietnamese Chinese
Taiwanese
Chinese nec
Indian nfd
Bengali
Fijian Indian
Gujarati
Indian Tamil
Punjabi
Sikh
Anglo Indian
Indian nec
Sri Lankan nfd
Sinhalese
Sri Lankan Tamil
Sri Lankan nec
Japanese
Korean
Afghani
Bangladeshi
Nepalese
Pakistani
Tibetan
Eurasian
Asian nec
Middle Eastern nfd
Algerian
Arab
Assyrian
Egyptian
Iranian/Persian
Iraqi
Israeli/Jewish
Jordanian
Kurd
Lebanese
Libyan
Moroccan
Omani
Palestinian
Syrian
Tunisian
Turkish
Yemeni
Middle Eastern nec
Latin American nfd
Argentinian
Bolivian
Brazilian
Chilean
Colombian
Costa Rican
Latin American Creole
Ecuadorian
Guatemalan
Guyanese
Honduran
Malvinian
Mexican
Nicaraguan
Panamanian
Paraguayan
Peruvian
Puerto Rican
Uruguayan
Venezuelan
Latin American nec
African nfd
United States Creole
Jamaican
Kenyan
Nigerian
African American
Ugandan
West Indian
Somali
Eritrean
Ethiopian
Ghanaian
African nec
Central American Indian
Inuit
North American Indian
South American Indian
Mauritian
Seychellois
South African Coloured
New Zealander
Other Ethnicity nec
Don't Know
Refused to Answer
Repeated Value
Response Unidentifiable
Response Outside Scope
Not Stated
Karen
Chin
Malaysian Indian
South African Indian
Bhutanese
Maldivian
Mongolian
Burundian
Congolese
Sudanese
Zambian
Other Zimbabwean
South Korea
North Korea
GP/Practice:
Referrer:
*
Long term condition:
*
Organisation:
*
Weight:
Weight date:
Blood pressure – systolic:
BP-Systolic date:
Height:
Blood pressure – diastolic:
BP-Diastolic date:
Level of physical activity (please tick):
30min > 5 days/week
30min > 4 days/week
30min > 3 days/week
30min > 2 days/week
30min > 1 days/week
ADLs only
No Activity
Additional Referral Detail
Consent to Refer:
*
Yes
No
Please ensure that your client has consented to this referral being made.
Reason For Referral:
*
Are you aware of any supports that are already in place for this patient?
Any risks/alerts for this patient?
Prove that you are not a robot:
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