Taranaki Referral Form - Extended Care Team

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:*

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

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?

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