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Aunty Jean's Program Referral Form

Fields marked with an * are required.

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*

Phone*

Referral Date*

For any enquires regarding referrals, please contact the Chronic Disease Outreach Nurse on 02 4365 2294 or email ccpc@ccpc.com.au

Health on The Streets Referral Form

Fields marked with an * are required.

REFERRER DETAILS

Organisation*

Name*

Phone Number*

Email Address*

PATIENT DETAILS

Name*

DOB

Address/location*

Phone Number*

Usual GP*

GP Practice*

ASSISTANCE REQUIRED

Outreach*

Clinical Care*

Preventative Care*

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

Aunty Jean's Program Referral Form

Health on The Streets Referral Form

Aboriginal and Torres Strait Islander Scholarship Form

Coast Nutrition Referral Form