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{\footerf\pard\plain\f0\fs24\par}\pard\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs28\b <<Miscellaneous:Practice Letterhead>>{\*\txfieldend}\plain\f0\fs28\b\par\par Home Medices Review Referral (HMR)\plain\f0\fs20\par\par\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 34000000}{\*\txfieldtext \plain\f0\fs20 <<Miscellaneous:Date>>}{\field{\*\fldinst { HYPERLINK "4" }}{\fldrslt{\plain\f0\fs20 <<Miscellaneous:Date>>}}}}\plain\f0\fs20\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx3211\clvertalt\cellx6422\clvertalt\cellx9633\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20\b General Practitioner Details  \plain\f0\fs20\cell\plain\f0\fs20\b Community Pharmacy Details\tab\plain\f0\fs20\cell\plain\f0\fs20\b Patient Details\plain\f0\fs20\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx3211\clvertalt\cellx6422\clvertalt\cellx9633\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Full Details>>{\*\txfieldend}\plain\f0\fs20\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Addressee:Full Address>>{\*\txfieldend}\plain\f0\fs20\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Full Details>>{\*\txfieldend}\plain\f0\fs20\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\par Dear {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Addressee:Greeting>>{\*\txfieldend}\plain\f0\fs20 ,\par\par Thank you for agreeing to see {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:First Name>>{\*\txfieldend}\plain\f0\fs20  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Surname>>{\*\txfieldend}\plain\f0\fs20 , age {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Age>>{\*\txfieldend}\plain\f0\fs20  with a view to conducting a Home Medicines Review for {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:him/her>>{\*\txfieldend}\plain\f0\fs20 .  The patient's current medications and condition summary is attached for your information.\par\par This patient fits the HIC criteria for HMR and has provided me with informed consent for you to proceed with this Item number.  I am this patient's usual GP.\par\par\plain\f0\fs20\b Relevant Progress Notes:\plain\f0\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Summary:Progress Notes (Selected)>>{\*\txfieldend}\plain\f0\fs20\par\par\plain\f0\fs20\b Relevant Investigations:\plain\f0\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Summary:Investigation Results (Selected)>>{\*\txfieldend}\plain\f0\fs20\par\par\plain\f0\fs20\b Past Medical History:\plain\f0\fs20\par\par\plain\f0\fs20\b Current medications:\plain\f0\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Clinical Details:Medication List>>{\*\txfieldend}\plain\f0\fs20\par\par\plain\f0\fs20\b Immunisation:\plain\f0\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Clinical Details:Immunisation List>>{\*\txfieldend}\plain\f0\fs20\par\par\plain\f0\fs20\b Allergies:  \plain\f0\fs20\par{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 52000000}{\*\txfieldtext \plain\f0\fs20 <<Clinical Details:Allergies>>}{\field{\*\fldinst { HYPERLINK "R" }}{\fldrslt{\plain\f0\fs20 <<Clinical Details:Allergies>>}}}}\plain\f0\fs20\par\par\plain\f0\fs20\b Social History:\plain\f0\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Clinical Details:Smoking>>{\*\txfieldend}\plain\f0\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Clinical Details:Alcohol>>{\*\txfieldend}\plain\f0\fs20\par\par\plain\f0\fs17\par\pard\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f0\fs20\b Equipment or Aids Used or Owned by the Patient:\plain\f0\fs18\b\par{\listtext\pard\plain\f0\fs20 1.\tab}\pard\fi-360\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0\plain\f0\fs20 Peak Flow Meter\tab\tab{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Peak Flow Meter>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Peak Flow Meter>>}}}}\plain\f0\fs20\par{\listtext\pard\plain\f0\fs20 2.\tab}\ls1\ilvl0 Nebuliser\tab\tab\tab{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Nebuliser>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Nebuliser>>}}}}\plain\f0\fs20\par{\listtext\pard\plain\f0\fs20 3.\tab}\ls1\ilvl0 Spacer\tab\tab\tab{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Spacer>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Spacer>>}}}}\plain\f0\fs20\par{\listtext\pard\plain\f0\fs20 4.\tab}\ls1\ilvl0 Blood Glucose Meter\tab{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Blood Glucose Meter>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Blood Glucose Meter>>}}}}\plain\f0\fs20\par{\listtext\pard\plain\f0\fs20 5.\tab}\ls1\ilvl0 Webster Pack\tab\tab{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Webster Pack>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Webster Pack>>}}}}\plain\f0\fs20\par{\listtext\pard\plain\f0\fs20 6.\tab}\ls1\ilvl0 Other - Please specify\tab{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c004d007c007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs20 <<Other - Please specify>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|M|||0|"}}{\fldrslt{\plain\f0\fs20 <<Other - Please specify>>}}}}\plain\f0\fs20\par\pard\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\line\plain\f0\fs18\b ISSUES THAT MAY INFLUENCE MEDICATION USE OR EFFECTIVENESS\par\plain\f0\fs20 1.\tab Vision\tab\tab\tab\tab\tab{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Vision difficulties>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Vision difficulties>>}}}}\plain\f0\fs20\par 2.\tab Language and/or literacy problems\tab\tab{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Language and/or literacy problems>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Language and/or literacy problems>>}}}}\plain\f0\fs20\par 3.\tab Cognition (memory and comprehension)\tab{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Cognition (memory and comprehension) problems>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Cognition (memory and comprehension) problems>>}}}}\plain\f0\fs20\par 4.\tab Hearing\tab\tab\tab\tab\tab{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Hearing difficulties>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Hearing difficulties>>}}}}\plain\f0\fs20\par 5.\tab Swallowing\tab\tab\tab\tab\tab{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Swallowing difficulties>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Swallowing difficulties>>}}}}\plain\f0\fs20\par 6.\tab Dexterity (eg manual coordination)\tab\tab{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Dexterity (eg manual coordination) difficulties>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Dexterity (eg manual coordination) difficulties>>}}}}\plain\f0\fs20\par{\listtext\pard\plain\f0\fs20 7.\tab}\pard\fi-360\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0 Other, please specify:\tab\tab\tab{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004d007c007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs20 <<Other difficulties - Please specify>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|M|||0|"}}{\fldrslt{\plain\f0\fs20 <<Other difficulties - Please specify>>}}}}\plain\f0\fs20\par\pard\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\line\par\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20\b Is Patient Self-medicated OR Carer-medicated?\par{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c004c007c007c007c00330030007c00530045004c0046002d004d00650064006900630061007400650064007c00430041005200450052002d004d00650064006900630061007400650064000000}{\*\txfieldtext \plain\f0\fs20\i <<SELF-Medicated/CARER-Medicated>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|L|||30|SELF-Medicated|CARER-Medicated"}}{\fldrslt{\plain\f0\fs20\i <<SELF-Medicated/CARER-Medicated>>}}}}\plain\f0\fs20\i\tab\plain\f0\fs20\b\i\par\plain\f0\fs20\par Current occupation is: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Occupation>>{\*\txfieldend}\plain\f0\fs20\par\par\plain\f0\fs20\b I HAVE EXPLAINED TO THE PATIENT:\plain\f0\fs20\par{\pntext\pard\plain\f2\fs20\'b7\tab}\pard\fi-360\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf2\pnfs20\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}the process in having a HMR; and\par\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\plain\f0\fs20\b THE PATIENT HAS CONSENTED:\plain\f0\fs20\par{\pntext\pard\plain\f2\fs20\'b7\tab}\pard\fi-360\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf2\pnfs20\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}to me releasing to the pharmacist information about their medical history and medications; and\par\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\plain\f0\fs20\b THE PATIENT UNDERSTANDS THAT:\plain\f0\fs20\par{\pntext\pard\plain\f2\fs20\'b7\tab}\pard\fi-360\li360\tx360\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf2\pnfs20\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}the location of the HMR is at their choice, but preferably in their own home; and\par{\pntext\pard\plain\f2\fs20\'b7\tab}\ls2\ilvl0{\*\pn\pnlvlblt\ilvl0\ls2\pnstart1\pnf2\pnfs20\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}the pharmacist who will conduct the HMR will communicate with me information arising from the HMR; and\par\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par Yours faithfully,\par\par\par\par\par\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Name>>{\*\txfieldend}\plain\f0\fs17\par\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par }