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{\footerf\pard\plain\f0\fs24\par}\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clcbpat4\cellx10785\pard\widctlpar\intbl\pard\intbl\qc\sa57\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs8\cf3\par\pard\intbl\qc\sa57\tx5415\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680\tx14400\plain\f0\fs24\b\cf3  MEDICATION MANAGEMENT REVIEW - REFERRAL FORM\par\pard\intbl\qc\sa57\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20\b\cf3 INCLUDING:\par Home Medicine Review (HMR) and Residential Medication Management Review (RMMR)\plain\f0\fs20\cell\intbl\row\pard\pard\s16\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs8  \plain\f0\fs20\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\cellx5386\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\cellx10772\pard\widctlpar\intbl\pard\s16\intbl\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18\b COMMUNITY PHARMACY DETAILS:\plain\f0\fs16\b\par\plain\f0\fs16 (nominated by the patient)\par\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20 Name: {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0043007c0030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs20 <<Name of Pharmacist?>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|C|0||0|"}}{\fldrslt{\plain\f0\fs20 <<Name of Pharmacist?>>}}}}\plain\f0\fs20\par\pard\s16\intbl\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18\b PATIENT / RESIDENT DETAILS:\plain\f0\fs16\b\par\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20 Name: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f0\fs20\par Address: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Full Address>>{\*\txfieldend}\plain\f0\fs20\par D.O.B: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:DOB>>{\*\txfieldend}\plain\f0\fs20\par Medicare No: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Medicare Number>>{\*\txfieldend}\plain\f0\fs20\par DVA No: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:DVA Number>>{\*\txfieldend}\plain\f0\fs20\par Patient/Carer/ Next of Kin contact: {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0043007c0030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs20 <<Patient/Carer contact?>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|C|0||0|"}}{\fldrslt{\plain\f0\fs20 <<Patient/Carer contact?>>}}}}\plain\f0\fs20\par\cell\pard\s16\intbl\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18\b GENERAL PRACTITIONER DETAILS:\plain\f0\fs16\b\par\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20 Name: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Name>>{\*\txfieldend}\plain\f0\fs20\par Address: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Full Address>>{\*\txfieldend}\plain\f0\fs20\par Provider No: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Provider Number>>{\*\txfieldend}\plain\f0\fs20\par Prescriber No: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Prescriber Number>>{\*\txfieldend}\plain\f0\fs20\par Phone: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Phone>>{\*\txfieldend}\plain\f0\fs20\par Fax: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Fax>>{\*\txfieldend}\plain\f0\fs20\par Email: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:E-mail>>{\*\txfieldend}\plain\f0\fs20\par\par .\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clcbpat4\cellx5386\clvertalt\clcbpat4\cellx10772\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs8  \cell  \cell\intbl\row\pard\pard\s16\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs12\b\par\plain\f0\fs18\b To mark the boxes below the box need to be selected and then press x on the keyboard. The box can be cleared by selecting the box and pressing the letter o on the keyboard\par\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs12\b\par\plain\f0\fs18\b 1\tab THIS REFERRAL IS FOR A:\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx3600\clvertalt\cellx6120\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 HMR (go to 3)\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 RMMR (go to 2)\plain\f0\fs18\b\cell\cell\cell\intbl\row\pard\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par 2\tab IF REFERRED FOR A RMMR, COMPLETE THIS SECTION:\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\cellx3960\clvertalc\cellx7380\clvertalc\cellx9188\clvertalc\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 Referral for a new or existing resident?\cell\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 New Resident\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f0\fs18  Existing Resident\plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\cellx3960\clvertalc\cellx7380\clvertalc\cellx9188\clvertalc\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 If new resident, date of admission to RACF?\cell\plain\f0\fs18\b\cell\plain\f2\fs22\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\cellx3960\clvertalc\cellx7380\clvertalc\cellx9188\clvertalc\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 If existing resident, RMMR provided previously?\cell\plain\f0\fs18\b\cell\plain\f2\fs22 o\plain\f0\fs18 Yes\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f0\fs18  No\plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\cellx3960\clvertalc\cellx7380\clvertalc\cellx9188\clvertalc\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 If yes, date RMMR previously provided \cell\plain\f0\fs18\b\cell\plain\f2\fs22\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\cellx3960\clvertalc\cellx7380\clvertalc\cellx9188\clvertalc\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 Advanced Medical Directive?\cell\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Yes\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f0\fs18  No\plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\cellx3960\clvertalc\cellx7380\clvertalc\cellx9188\clvertalc\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 Enduring Medical Power of Attorney?\cell\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Yes\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f0\fs18  No\plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\cellx3960\clvertalc\cellx7380\clvertalc\cellx9188\clvertalc\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 Power of Attorney Details (if appointed)\cell Name:\cell\plain\f0\fs18\b\cell\plain\f2\fs22\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalc\cellx3960\clvertalc\cellx7380\clvertalc\cellx9188\clvertalc\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18\b\cell\plain\f0\fs18 Phone:\cell\plain\f2\fs22\cell\cell\intbl\row\pard\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18\b\par\par 3\tab OTHER PATIENT INFORMATION:\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 Height: \plain\f0\fs18\b\cell{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c004e007c0030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs18 <<Patient Height (cm)?>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|N|0||0|"}}{\fldrslt{\plain\f0\fs18 <<Patient Height (cm)?>>}}}}\plain\f0\fs18\b  \plain\f0\fs18 cm\plain\f0\fs18\b\cell\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 Weight:\plain\f0\fs18\b\cell{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c004e007c0030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs18 <<Patient Weight (kg)?>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|N|0||0|"}}{\fldrslt{\plain\f0\fs18 <<Patient Weight (kg)?>>}}}}\plain\f0\fs18\b  \plain\f0\fs18 kg\plain\f0\fs18\b\cell\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 Blood Pressure:\plain\f0\fs18\b\cell{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0043007c0030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs18 <<Patient Blood Pressure?>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|C|0||0|"}}{\fldrslt{\plain\f0\fs18 <<Patient Blood Pressure?>>}}}}\plain\f0\fs18\b\cell\cell\cell\intbl\row\pard\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Does the patient smoke?\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Clinical Details:Smoking>>{\*\txfieldend}\plain\f0\fs18\cell\plain\f0\fs18\b\cell\cell\intbl\row\pard\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Does patient drink alcohol?\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Clinical Details:Alcohol>>{\*\txfieldend}\plain\f0\fs18\cell\plain\f0\fs18\b\cell\cell\intbl\row\pard\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\pard\s16\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 4\tab MEDICATION DOSE ADMINISTRATION (mark who administers medication)\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Self\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Partner / Carer\plain\f0\fs18\b\cell\cell\cell\intbl\row\pard\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\par 5\tab AIDS OR OTHER EQUIPMENT USED (mark if used)\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Peakflow meter \plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Spacer\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Nebuliser\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f0\fs18  Other \plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Blood Glucose Meter\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Webster Pack /Dosette\plain\f0\fs18\b\cell\cell\cell\intbl\row\pard\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\par 6\tab MEDICATION USE OR EFFECTIVENESS ISSUES (mark if an issue)\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f2\fs22 o\plain\f0\fs18  Vision\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f0\fs18   Hearing\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Swallowing\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Other\plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Cognition\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f0\fs18   \plain\f0\fs17 Language and/or\plain\f0\fs16  literacy\plain\f0\fs18\b\cell\plain\f2\fs22 q\plain\f0\fs18   \plain\f0\fs17 Dexterity\plain\f0\fs18\b\cell\cell\intbl\row\pard\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par 7\tab VACCINATIONS (mark if up to date)\plain\f0\fs20\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Influenza\plain\f0\fs20\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Tetanus \plain\f0\fs20\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Hepatitis A\plain\f0\fs20\cell\plain\f2\fs22 o\plain\f3\fs18  \plain\f0\fs18 Other\plain\f0\fs20\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2749\clvertalt\cellx5498\clvertalt\cellx8247\clvertalt\cellx10996\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Pneumovax\plain\f0\fs20\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Rubella\plain\f0\fs20\cell\plain\f2\fs22 q\plain\f3\fs18  \plain\f0\fs18 Hepatitis B\plain\f0\fs20\cell\cell\intbl\row\pard\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\plain\f0\fs18\b 8\tab INDICATION FOR HMR / RMMR (mark appropriate reasons)\par\plain\f2\fs22 q \plain\f0\fs20 Currently taking 5 or more regular medications;\plain\f1\fs20\par\plain\f2\fs22 q \plain\f0\fs20 Taking more than 12 doses of medication per day;\plain\f1\fs20\par\plain\f2\fs22 q \plain\f0\fs20 Significant changes made to medication treatment regimen in the last 3 months;\plain\f1\fs20\par\plain\f2\fs22 q \plain\f0\fs20 Medication with a narrow therapeutic index or medications requiring therapeutic monitoring;\plain\f1\fs20\par\plain\f2\fs22 q \plain\f0\fs20 Symptoms suggestive of an adverse drug reaction;\plain\f1\fs20\par\plain\f2\fs22 q \plain\f0\fs20 Sub-optimal response to treatment with medicines;\plain\f1\fs20\par\plain\f2\fs22 q \plain\f0\fs20 Suspected non-compliance or inability to manage medication   related therapeutic devices;\plain\f1\fs20\par\plain\f2\fs22 q \plain\f0\fs20 Patients having difficulty managing their own medicines because of literacy or language difficulties, dexterity problems or impaired sight, confusion/dementia or other cognitive difficulties; \par\plain\f2\fs22 q \plain\f0\fs20 Patients attending a number of different doctors, both general practitioners and specialists; and\plain\f1\fs20\par\plain\f2\fs22 q \plain\f0\fs20 Recent discharge from a facility / hospital (in the last 4  weeks).\par\plain\f2\fs22 q \plain\f0\fs20 Other: \par\plain\f0\fs18\b\par 9\tab ALLERGIES OR ADVERSE REACTIONS TO MEDICATION\par\par{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 0000}{\*\txfieldtext \plain\f0\fs18 <<Clinical Details:Allergies>>}}\plain\f0\fs18\b\par\par{\listtext\pard\plain\f0\fs18\b 10\tab}\pard\s16\tx720\tx1080\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0 CURRENT MEDICATION:\par\pard\s16\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\par\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Clinical Details:Medication List>>{\*\txfieldend}\plain\f0\fs18\par\par{\listtext\pard\plain\f0\fs18\b 11\tab}\pard\s16\tx720\tx1080\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0\plain\f0\fs18\b CURRENT CONDITIONS and ISSUES:\par\pard\s16\tx720\tx1080\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\par\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 0000}{\*\txfieldtext \plain\f0\fs18 <<Clinical Details:History List>>}}\plain\f0\fs18\par\par\par\plain\f0\fs18\b 12\tab ANY RELEVANT LABORATORY RESULTS AND BLOOD DRUG LEVELS\par\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Summary:Investigation Results (Selected)>>{\*\txfieldend}\plain\f0\fs18\b\par\par\par\trowd\trgaph30\trleft26\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5036\clvertalt\cellx10772\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 I HAVE EXPLAINED TO THE PATIENT/ **RESIDENT:\par{\pntext\pard\intbl\plain\f4\fs18\'b7\tab}\pard\s16\intbl\fi-360\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf4\pnfs18\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}\plain\f0\fs18 the process involved in having a HMR / RMMR; and\par\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18\b\par THE PATIENT / **RESIDENT UNDERSTANDS THAT:\par{\pntext\pard\intbl\plain\f4\fs18\'b7\tab}\pard\s16\intbl\fi-360\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf4\pnfs18\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}\plain\f0\fs18 the location of the HMR is at their choice, but preferably in their own home; \par{\pntext\pard\intbl\plain\f4\fs18\'b7\tab}\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf4\pnfs18\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}the location of the RMMR is usually within the RACF and\par{\pntext\pard\intbl\plain\f4\fs18\'b7\tab}\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf4\pnfs18\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}the pharmacist who will conduct the HMR / RMMR will communicate with me, information arising from the HMR / RMMR; \par\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18\b\par THE PATIENT / **RESIDENT HAS CONSENTED:\par{\pntext\pard\intbl\plain\f4\fs18\'b7\tab}\pard\s16\intbl\fi-360\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf4\pnfs18\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}\plain\f0\fs18 to me releasing to the pharmacist information about their medical history and medications; and\par\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\plain\f0\fs18\b\cell THE  PATIENT / **RESIDENT HAS CONSENTED:\par{\pntext\pard\intbl\plain\f4\fs18\'b7\tab}\pard\s16\intbl\fi-360\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf4\pnfs18\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}\plain\f0\fs18 to me releasing their Medicare No. or DVA No. to the pharmacist for the pharmacist's payment purposes.*\par\pard\s16\intbl\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\par\plain\f0\fs18\b THE PATIENT / **RESIDENT:\par\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f2\fs22\tab q \plain\f0\fs18 does \plain\f2\fs22  \tab q \plain\f0\fs18 does not  \tab\plain\f2\fs22 q\plain\f0\fs22  \plain\f0\fs18 Not Applicable\par{\pntext\pard\intbl\plain\f4\fs18\'b7\tab}\pard\s16\intbl\fi-360\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf4\pnfs18\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}consent for the pharmacist to liaise  with an appropriate member of  #\tab\tab\tab                             about this HMR / RMMR.\plain\f0\fs18\b\par\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs16       \line  (# service provider type)\par\par\plain\f0\fs18\par General Practitioner's Signature:\par\par Date: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Miscellaneous:Date>>{\*\txfieldend}\plain\f0\fs18\b\cell\intbl\row\pard\trowd\trgaph30\trleft26\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5036\clvertalt\cellx10772\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18\b\cell\cell\intbl\row\pard\pard\s16\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs16\b\par **If a third party holds Power of Attorney authority or similar, consent to the HMR / RMMR can be provided by the authorised person  \par\plain\f0\fs18\par Note: If the patient does not agree to releasing their Medicare No., the HMR / RMMR service can still be provided.\par\plain\f0\fs18\b\par\plain\f0\fs18 ............................................................................................................................................................................................\par\plain\f0\fs18\b\par ACKNOWLEDGEMENT OF RECEIPT OF REFERRAL\par\par\plain\f0\fs18 From (community pharmacy) ............................................................................................................................................\par\par I have arranged to conduct a HMR / RMMR for {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs18 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f0\fs18\b  \plain\f0\fs18 on ......................................................  \par\par Pharmacist conducting interview ......................................................................................................................................\par\plain\f0\fs18\b\par\plain\f0\fs18\par\par\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371 Signed .....................................................................\par\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par }