OFFICIAL: Sensitive//Medical in confidence
	
Trial #295

	

Pulmonary Rehabilitation Referral Form

	
Flinders Medical Centre Level 2	

        Tel: (08) 8204 7550 
        Fax: (08) 8204 5632	

	
Noarlunga GP Plus	

        Tel: (08) 8164 9111 
        Fax: (08) 8164 9199	

	
Either Location	

Respiratory diagnosis (REQUIRED)	
Attach patient sticker/complete demographics	

	
   COPD	

	
   Asthma	

	
   ILD	

	
   Respiratory Failure	

	
  Cor Pulmonale	

	
  Other (specify)	

	

	

Current Smoker:	

	

Yes	

	

No	

	
 Family Name:   <<Patient Demographics:Surname>>      
 Given Names:  <<Patient Demographics:First Name>>   <<Patient Demographics:Middle Name>>
 Address:  <<Patient Demographics:Full Address>>
 D.O.B: <<Patient Demographics:DOB>>
 Contact Number:
 Home: <<Patient Demographics:Phone (Home)>>  
 Mobile: <<Patient Demographics:Phone (Mobile)>>  
Medications:	

Respiratory:  

	

	

Home oxygen	
 Other:	

If so, Prescription details:

	

	

	

	

Significant comorbidities / relevant issues: (please specify)	

	
Psychological issues	

	
Cardiac comorbidities	

	
Musculoskeletal limitations	

	
Other (please list)	

	

Main reason for referral:	

	

Education	

	

Exercise program	

	

Smoking cessation	

	

Address psychological comorbidities	

	

Other

Nb: Mandatory data for referral consideration:	

TESTS PERFORMED IN THE LAST 12 MONTHS (MANDATORY)

	
PFTs in the last 12 months. If completed, where:	

	

Date:	

	

TESTS PERFORMED IN THE LAST 6 MONTHS

	
ABG, If completed, where:	

	

Date:	

	

	

6MWT, If completed, where:	

	

Date:	

	

	

CXR, If completed, where:	

	

Date:	

	

	

ECG/Echo, If completed, where:	

	

Date:	

	

Please attach relevant results with referral.

Transport required?: (please see elegibility criteria)	

	

Yes	

	

No	

	

Entitled Veteran	

	

Pension cardholder	

Referring professional: (REQUIRED)	
General practitioner: (REQUIRED)	

Name:	
<<Miscellaneous:Current User>>	

Address:	
<<Practice/Location:Name>>
<<Practice/Location:Address>>	

Signature:	

Date:	
<<Miscellaneous:Date>>	

Name:	

Address:	
  <<Practice/Location:Name>>
  <<Practice/Location:Address>>	

Telephone:	
  <<Practice/Location:Phone>>	

Office Use:	

Triage Date:	
	
Priority:  	

	

	

Pulmonary Rehabilitation Guidelines	

Patients referred into the Pulmonary Rehabilitation program will be triaged and enrolled based on their eligibility.
 
Eligibility Criteria 

Include patients who: 

• Have Chronic Obstructive Pulmonary 
Disease (COPD) or other respiratory 
conditions 

• Are recovering from an acute 
exacerbation of their respiratory 
condition 

• Are willing to participate in group 
exercise and education classes (even 
if they are current smokers) 

Exclude patients who: 

• Do not have a diagnosis of 
respiratory disease 

• Musculoskeletal or neurological 
disorders that prevent exercise. 
These patients may be considered 
for a modified program subject to 
availability. 

• Have acute unstable respiratory 
illness 

• Severe cognitive impairment or 
psychotic disturbance 

• Breathing difficulties despite normal 
lung function 

• Unable to meet attendance 
requirements. 
	
Transport Eligibility Criteria 

Include patients who: 

• Are immobile and are unable to use 
an access cab, Medi-ride, Red Cross 
or other transport company 
AND 

• Are unable to catch public transport 
due to a disability 
AND 

• Have an up to date Medicare card 
(this is mandatory) 
OR 

• Have a DVA card (eligible for DVA 
transport). 	
Pulmonary Rehabilitation 
Program Triaging 

Patients are triaged by the Pulmonary 
Rehabilitation Team 

Category/Priority I 

(Offered a place in next available 
program) 

• Moderate to severe COPD after 
recent exacerbation 

• Post-lobectomy/pneumonectomy 

• Lung transplant recipients/wait list 
Category/Priority II 

• COPD 

• Interstitial Lung Disease 

• Pulmonary Arterial Hypertension 
Category/Priority III 

• Anyone from Category II with history 
of failing to attend 

• Attended Pulmonary Rehab in the 
last 18 months. 

___________________________________________________________________________________________________
For more information: 
Department of Respiratory Medicine 
Level 6 
Flinders Medical Centre 
Bedford Park SA 5042 
Telephone: 08 8204 7550 	
Pulmonary Rehabilitation 
Ground Floor 
Noarlunga GP Plus 
Noarlunga Centre SA 5168 
Telephone: 08 8164 9111 (option 1) 	

	

OFFICIAL: Sensitive//Medical in confidence