Any patients living in Western Australia with asthma and/or COPD 
can be referred to our fully bulk billed services.
Please complete all sections and attach all relevant patient documents
including Asthma/COPD Action Plan and Patient Management Plan.

Referral From	
Referral From		
Name:		
Provider Number:		
Phone:		

Secure Messaging	Healthlink address ID: waasthma

Fax			(08) 9289 3601
Post			Respiratory Care WA
36 Ord Street
West Perth, WA 6005

Patient Details	
First name(s):		
Family name:		
Preferred name:		
Title:		
Date of birth:		
Gender:		
Address incl. 
Street, City, State.		
Mailing address 
(if different):			
Post code:		Email:		
Telephone no.		
Home phone:		Work phone:		
Mobile:		Fax		

Special needs:		
Is an interpreter required?		If yes, language/dialect:		
Other special needs:	

Medicare eligible:		
Medicare number:		Ref:		Expiry:		

Next of kin/Guardian		
Full name:		
Relationship:		
Phone:		

		
Patient is aware we will contact them to confirm appointment via email/SMS information provided on the referral.	

Consent for email confirmation of appt times
Consent for SMS confirmation of appt times
Consent for both email/SMS confirmation of appt times

Referral Details	
Is the referrer the usual GP for the patient?		
If no, name of usual GP:		
Contact number:		
Length of referral:		
Is this a renewed referral?                    		
Is the referrer the usual GP for the patient?		

Reason for referring:		
Adult Respiratory Hub (Includes lung function testing, Registered Nurse assessment/education, Specialist Review if necessary)

Children’s Respiratory Hub (Includes lung function testing, Registered Nurse assessment/education, Specialist Review if necessary)	
	
Diagnosis: 			Suspected asthma   			Confirmed asthma 	
				Suspected COPD 			Confirmed COPD 
				Undiagnosed / Other
	
Chronic Condition Management Plan (CCMP) initiated 	YES   		 NO   		Unsure   	N/A

If yes, has the CCMP been updated in the last 3 months?     YES    		 NO   		Unsure  

Asthma / COPD Action Plan initiated   			YES     		 NO  		Unsure  	 	N/A

If yes, has Action Plan been updated in the last 3 months?   YES     		NO   		Unsure  

** Any recommendations for CCMP or Action Plan updates by a Respiratory Care WA Health Professional will be provided in the report for GP to review with the patient. **Respiratory Care WA does not Medicare bill for this activity.

Clinical Information	
Observations:		
Percentile, height & weight:		
Current problem:		
Past history:		
Current medications:		
Allergies:		
Other clinical information:		
Family history:		
Social history:		

Additional Clinical Information	

Has your patient utilised emergency / urgent care resources in the past 12 months?   YES   NO  
If yes:

  1-2
  3-5
  5+ 

Has your patient required antibiotics for treatment of respiratory complications in the past 12 months?   YES   NO
If yes:

  1-2
  3-5
  5+ 

Has your patient required oral corticosteroids for treatment of their respiratory condition in the past 12 months?   YES   NO
If yes:

  1-2
  3-5
  5+

Other Relevant Clinical Information