PalCare

Indigenous Status:
Gender:
Country of Birth:
Ethnic List:
Marital Status:
Cultural and Linguistic Diversity:	Yes No Unknown
Specific Cultural Needs:
Language Spoken:
Communication Method:
Interpreter/Translator Required:	Yes No Not Stated / Inadequately Described
Interpreter Language Required:
Insurance Status:
Insurer:
Insurance Card Number:
Insurance Description:
Pension Type & Number:
Medicare Number:
Dept/Veterans' Affairs Number:
Telehealth (assessed suitability):
Telehealth (assessed suitability) Comment:

Reason For Referral: *	Symptom Management Respite Care Counselling End Stage Care Other
Reason For Referral - Details: *
Date of Diagnosis:	Estimated?
Primary Diagnosis: *
Specific Diagnosis: *
Other Diagnosis / Medical Conditions: *
Allergies:	Yes No Unidentified
Relevant Social History: *
Home Environment Risk Factors:	Yes No Unknown Details
Is Advance Care Plan:	In Place Discussed Not Discussed Unknown Declined
Legal/Custodial Issues:	Yes No Unknown Details
Client Aware of Referral: *	Yes No Unknown
Client Aware of Diagnosis: *	Yes No Unknown
Insight into Prognosis:	None Realistic Insight Some Insight
Hospital admission planned discharge date:

Availability:	Sun Mon Tue Wed Thu Fri Sat Home Visits After Hour Contacts
After Hours Contact:
Mobile:
Email:

I am willing to participate in multi disciplinary care plans and case conferences:	No Yes

Availability:	Sun Mon Tue Wed Thu Fri Sat Home Visits After Hour Contacts
After Hours Contact:
Mobile:
Email:

Availability:	Sun Mon Tue Wed Thu Fri Sat Home Visits After Hour Contacts
After Hours Contact:
Mobile:
Email:

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Referral for Specialist Palliative Care