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PATIENT DETAILS
Name*
DOB*
Address*
Phone*
GP Name/Practice*
Has patient consented to referral?*YesNo
GPMP and/or TCA attached?*YesNo
Has patient had health check ≤ 12 months?*YesNo
If yes, when was this health check?
 
ELIGIBILITY CRITERIA
Is patient Aboriginal and/or Torres Strait Islander:*YesNo
Patient must have at least ONE of the following conditions:*DiabetesChronic Respiratory DiseaseCancerCardiovascular DiseaseChronic Kidney Disease
Please specify other health condition/s:
Participation in Aunty Jeans Aboriginal Chronic Care Program includes exercise sessions which are supervised by an Accredited Exercise Physiologist. Sub-maximal exercise testing pre and post program will be conducted.
Your patient will be given an individualised exercise program including warm up, aerobic exercises, resistance training, stretching and cool down. All exercises will be performed at a light to moderate intensity. The exercise testing may involve a 6-minute walk test, stationary bike test and a sit to stand test. Should any of the contraindications below be observed exercise will not be undertaken and appropriate care will be provided:
Unstable angina
Symptoms such as chest discomfort, shortness of breath on low activity
Uncontrolled cardiac failure
Severe aortic stenosis
Uncontrolled hypertension (systolic BP ≥ 180mmHg, diastolic BP ≥ 110mmHg)
Acute infection or fever
Resting tachycardia/arrhythmia
Uncontrolled diabetes (e.g. blood glucose < 6mmol/L or > 15 mmol/L)
REFERRER DETAILS
Referrer Name*
Referrer Practice*
Email*
Referral Date*
For any enquires regarding referrals, please contact the Chronic Disease Outreach Nurse on 02 4365 2294 or email ccpc@ccpc.com.au
Organisation*
Phone Number*
Email Address*
DOB
Address/location*
Usual GP*
GP Practice*
ASSISTANCE REQUIRED
Outreach*YesNoUnsure
Clinical Care*YesNoUnsure
Preventative Care*YesNoUnsure
Other
ADDITIONAL INFORMATION
Current level of engagement with your service (i.e. frequency and length of time)
Please list risks for outreach engagement
Other services/organisations engaged with this person
Priority for support*1. Urgent2. High Priority3. Medium Priority4. Low Priority5. No Priority
Contact Number*
Gender Identity*
Do you identify as an Aboriginal or Torres Strait Islander person?*YesNo
Course details and institution*
Year study commenced*
Expected year of completion*
Will you require a placement?*YesNo
How many hours of placement*
Learning institution contact information eg supervisor, student support*
Are these studies full-time or part-time*Full-timePart-time
What learning resources are you planning to use the scholarship funds forLaptopTabletMouse and keyboardTextbooksStationery itemsOther - please specify below
Upload resume (PDF or Word)*
Upload cover letter (PDF or Word)*
Upload confirmation of enrolment (PDF or Word)*
Referring Organisation*
CLIENT DETAILS
Client Name*
Aboriginal or Torres Strait Islander Status*AboriginalTorres Strait IslanderAboriginal & Torres Strait IslanderNeitherUnknown/prefer not to say
Medicare Number*
Gender*MaleFemalePrefer not to say
GP Name*
Do you have any concerns for dieticians providing home visits?*
CARER DETAILS (if applicable)
Carer Name
Phone Number
REFERRAL DETAILS
Reason for referral?*
CLIENT INFORMATION
Weight*
Height*
Weight History*
Recent Weight Loss*YesNo
If Yes, how much?
CONFIRMATION OF REFERRAL VIA MyAgedCare (MAC) NATIONAL GATEWAY
Referral submitted to My Aged Care National Gateway on*
MAC Number*
For any enquires regarding referrals, please contact the Team Leader Community Programs on 02 4365 2294 or email ccpc@ccpc.com.au
Your name
Your email
GPRegistered NurseMidwifeRegistered ParamedicPractice Administration
Fields marked with an * are required
First Name*
Last Name*
Area of interestHome and Community Support WorkAdministrationCoordinator of SupportsMental Health OfficerProject OfficerGeneral PractitionerAllied Health ProfessionalClinician
Upload cover letter (PDF or Word)
.
Profession
Practice
Contact Number
Area of interestNDISAdministrationCommunity ProgramsHoTSGeneral PractitionerAllied Health Professional