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. <Please direct an acutely unwell child to the Emergency Department.>
<Please consider the referral criteria available at www.childrens.health.qld.gov.au/referapatient>
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Referred to: <<Referred to:>>
Specialist requested if different to above: <Specialist requested if different to above>
Referrals are shared with other specialists to ensure patients are seen as quickly as possible.
Referral date:   <TodaysDate>
Length of referral: <Length of referral>
Telehealth Referral: <Is this a Telehealth Referral>

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Patient Details
Re: <PtFullName>
DOB: <PtDoB>  	Age: <PtAge>   	
Sex: <PtSex>

Medicare Number:<PtMCNo>  	Expiry: <PtMCExpiry>         

Address:
<PtAddress>

Patient Home Phone: <PtPhoneH>
Patient Mobile Phone: <PtPhoneMob>

Parental Contact 1: <HOFName>, <HOFAddress> 
Parental Contact 2: <NOKName>, <NOKContact>, <NOKContact2>, <NOKRelation>

Out of home care? <Is the child in out of home (foster) care?> If yes, Name of Child Safety Service Centre? <If in Out of Home Care, Name of Child Safety Service Centre?>
Are there any custody or guardianship issues regarding this patient? <Are there any custody or guardianship issues regarding this patient?>

Aboriginal or Torres Strait Islander origin:  <PtEthnicity>
Interpreter required: <Interpreter required:>   If yes ,what is the preferred language: <If yes, what is the preferred language? >

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Clinical Referral Information
Reason for Referral: <Brief Provisional Diagnosis / Presenting Condition>

Is the Referral High Risk or Urgent: <Is the referral High Risk or Urgent?>
Reason if High Risk or Urgent: <If High Risk or Urgent, Please specify details>

Background:
<Background of the Presenting Condition & Clinical Question (Your clinical letter)>
Duration, Severity & Treatment to Date:
<Please Comment on the duration, severity and treatment to date>
Clinical Modifiers:
<Clinical Modifiers>

Past Medical History: <SelectedPMH>

Current medications: <SelectedRx>

Allergies: <Reactions> 

Immunisation status: <Immunisation status> 

Social history and/or Psychosocial risk factor(s): <Social history and/or Psychosocial risk factor(s) - comment on home visit safety if child health referral>
Background Social History: <SocialHx>
Relevant Family History: <FamilyHx>

Developmental History:
Concerns with Thinking and Learning?	 <Concerns with Thinking and Learning?>	
Concerns with Communication? 	 <Concerns with Communication?>	
Concerns with Movement Skills?	 <Concerns with Movement Skills?>	
Concerns with Social / Play / ADLs?	 <Concerns with Social / Play / ADLs?>	
Concerns with Emotional Wellbeing Skills?	 <Concerns with Emotional Wellbeing Skills?>	
Concerns with Concentration / Executive Function?	 <Concerns with Concentration / Executive Function?>	

Details if concern with developmental domains:
<Details if concern with developmental domains:>

What additional documents have been faxed or sent: <What additional documents have been faxed/sent?>

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Referring Doctor Details
Doctor : <DrName>
Provider No.: <DrProviderNo>
Doctor Address:
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>

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

Is anyone else involved in the care of the patient?  <Is anyone else involved in the care of this patient?>

Verification

Signed: <DrName>
QCH Referral v6.4 BP 190701
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Relevant Investigations: 
<Ix>

Previously Recorded Observations:
<Observations>