Children's Health Queensland 
Hospital and Health Service
	Queensland Children’s Hospital
501 Stanley Street,South Brisbane Qld 4101
Hospital switchboard: (07) 3068 1111
Medical Objects ID: (RQ402900084)
Referral Fax: 1300 407 281	
Please Direct an Acutely Unwell Child to the Emergency Department.Acutely unwell to ED
Referral criteria 
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Referred to:   * Referred to
Specialist requested if different to above: Specialist requested
Referrals are shared with other specialists to ensure patients are seen as quickly as possible.
Referral date:  Miscellaneous.Date
Length of referral: Length of referral 
Telehealth Referral: Telehealth Referral

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Patient Details
Re: Patient Demographics.Full Name
DOB:Patient Demographics.DOB  	Age: Patient Demographics.Age   	
Sex: <Patient Demographics.Gender

Medicare Number:Patient Demographics.Medicare Number 	Expiry: Patient Demographics.Medicare Expiry Date         

Address:
Patient Demographics.Address

Patient Home Phone: Patient Demographics.Phone (Home)
Patient Mobile Phone: Patient Demographics.Phone (Mobile)

Parental Contact 1: Head of Family.Name, Head of Family.Address
Parental Contact 2: Patient Demographics.NOK Name, Patient Demographics.NOK Mobile Phone, Patient Demographics.NOK Home Phone, Patient Demographics.NOK Relationship

Out of home care?Child in out of home  If yes, Name of Child Safety Service Centre? yes,Name of Service 
Are there any custody or guardianship issues regarding this patient? Custody/Guardianship

Aboriginal or Torres Strait Islander origin: Aboriginal or Torres 
Interpreter required: Interpreter required   If yes ,what is the preferred language: yes, preferred lan

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Clinical Referral Information
Reason for Referral: Brief Diagnosis 

Is the Referral High Risk or Urgent: High Risk/Urgent
Reason if High Risk or Urgent: If Yes details

Background:
Background Condition
Duration, Severity & Treatment to Date:
Duration,severity
Clinical Modifiers:
Clinical Modifiers

Past Medical History:Clinical Details.History List>

Current medications: Clinical Details.Medications - Current PRN (with comments)

Allergies: Clinical Details.Allergies

Immunisation status: Clinical Details.Immunisation List

Social history and/or Psychosocial risk factor(s): Social History risks
Background Social History: Clinical Details.Social History
Relevant Family History: Clinical Details.Family History

Developmental History:
Concerns with Thinking and Learning?	Concerns Thinking	
Concerns with Communication? 	ConcernsCommunicatio	
Concerns with Movement Skills?	ConcernsMovement 	
Concerns with Social / Play / ADLs?	Concerns Social/Play	
Concerns with Emotional Wellbeing Skills?	Concerns Emotional 	
Concerns with Concentration / Executive Function?	Comcerns Concentrati	

Details if concern with developmental domains:
Details of Concern 

What additional documents have been faxed or sent: Additional docs fax

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Referring Doctor Details
Doctor : Treating Doctor.Name
Provider No.: Treating Doctor.Provider Number
Doctor Address:
Practice.Name
Practice.Address
Phone:Practice.Phone
Fax: Practice.Fax

Patient’s Usual G.P. (if different from referrer): Usual GP if differen

Is anyone else involved in the care of the patient?  Anyone else involved

Verification

Signed: Treating Doctor.Name
QCH referral v6.2.1 ZedMd  190701
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Relevant Investigations: 
Clinical Details.Result List (Selected)

Previously Recorded Observations:
Clinical Details.Selected Most Recent Measures