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{\footer\pard\qc\plain\f0\fs16\i\cf3 ACH Group is bound by National Privacy Principles in the Privacy Act 1988.  These principles regulate the way we handle personal information about persons referred to our service.  Please ask for a copy of our Privacy Statement for more information.\par}\pard\s17\qc\tqc\tx4153\tqr\tx8306\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680\tx14400\tx15120\tx15840\tx16560\plain\f0\fs40\b\cf4 ACH Group Health Services\par\plain\f0\fs16\cf4 ABN 99 437 071 895\par\plain\f0\fs8\cf4\par\plain\f0\fs24\cf4 Phone  \plain\f0\fs24\b\cf4 1300 300 811  \plain\f0\fs24\cf4   Fax  \plain\f0\fs24\b\cf4 8357 3255\par\plain\f0\fs24\cf4 Argus Email  \plain\f0\fs24\b\cf4 healthsecure@ach.org.au\plain\f0\fs24\cf4\par\pard\qc\tx4988\tx5697\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680\tx14400\tx15120\tx15840\plain\f0\fs24\cf4 Medical Objects\plain\f0\fs24\b\cf4   ACH Group Health Services\par\plain\f0\fs4\b\par\plain\f0\fs40\b Community Lifestyle Package Referral\par\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2061\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5046\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx6936\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Name of Patient\plain\f0\fs22\cf5\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f0\fs22\cell\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Date of Referral\plain\f0\fs22\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Miscellaneous:Date>>{\*\txfieldend}\plain\f0\fs22\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2061\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5046\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx6936\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Date of Birth\plain\f0\fs22\cf5\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Patient Demographics:DOB>>{\*\txfieldend}\plain\f0\fs22\cell\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Name of GP\plain\f0\fs22\cf5\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Doctor:Name>>{\*\txfieldend}\plain\f0\fs22\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2061\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5046\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx6936\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Address\plain\f0\fs22\cf5\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Patient Demographics:Address>>{\*\txfieldend}\plain\f0\fs22\cell\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Name of Clinic\plain\f0\fs22\cf5\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Practice:Name>>{\*\txfieldend}\plain\f0\fs22\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2061\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5046\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx6936\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Suburb\plain\f0\fs22\cf5\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Patient Demographics:City>>{\*\txfieldend}\plain\f0\fs22  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Patient Demographics:Postcode>>{\*\txfieldend}\plain\f0\fs22\cell\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Phone\plain\f0\fs22\cf5\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Doctor:Phone>>{\*\txfieldend}\plain\f0\fs22\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2061\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5046\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx6936\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Phone\plain\f0\fs22\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371 Hm: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Patient Demographics:Phone (Home)>>{\*\txfieldend}\plain\f0\fs22\par Wk: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Patient Demographics:Phone (Work)>>{\*\txfieldend}\plain\f0\fs22\cell\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Fax\plain\f0\fs22\cf5\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Doctor:Fax>>{\*\txfieldend}\plain\f0\fs22\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs12\par\trowd\trgaph30\trleft0\trpaddl40\trpaddt40\trpaddr30\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2043\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5046\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx6936\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 *Alternative Contact\plain\f0\fs22\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0043007c0030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs22 <<ALTERNATIVE CONTACT>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|C|0||0|"}}{\fldrslt{\plain\f0\fs22 <<ALTERNATIVE CONTACT>>}}}}\plain\f0\fs22\cell\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Contact's Relation to Patient\plain\f0\fs22\cf5\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0043007c0030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs22 <<    Contact's Relation to Patient>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|C|0||0|"}}{\fldrslt{\plain\f0\fs22 <<    Contact's Relation to Patient>>}}}}\plain\f0\fs22\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl40\trpaddt40\trpaddr30\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat4\cellx2043\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\cellx5046\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat4\cellx6936\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Alternative Contact's Phone\plain\f0\fs22\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0043007c0030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs22 <<    Alternative Contact's Phone>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|C|0||0|"}}{\fldrslt{\plain\f0\fs22 <<    Alternative Contact's Phone>>}}}}\plain\f0\fs22\cell\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Reason for Alternative Contact\plain\f0\fs22\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c00340034007c00480065006100720069006e00670020006900730073007500650073007c004d0065006d006f007200790020006900730073007500650073007c004c0061006e006700750061006700650020006900730073007500650073000000}{\*\txfieldtext \plain\f0\fs22 <<    Reason for Alternative Contact>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||44|Hearing issues|Memory issues|Language issues"}}{\fldrslt{\plain\f0\fs22 <<    Reason for Alternative Contact>>}}}}\plain\f0\fs22\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18 *If patient has \plain\f0\fs18\b hearing, memory or language issues\plain\f0\fs18 , please provide alternative contact details\plain\f0\fs22\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs12\par\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2058\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5781\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Services\par Menu\plain\f0\fs22\cf5\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22 Diabetes: {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c0036007c005900650073007c004e006f000000}{\*\txfieldtext \plain\f0\fs22 <<SERVICES: DIABETES>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||6|Yes|No"}}{\fldrslt{\plain\f0\fs22 <<SERVICES: DIABETES>>}}}}\plain\f0\fs22\par     New Diagnosis: {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c0036007c005900650073007c004e006f000000}{\*\txfieldtext \plain\f0\fs22 <<    If Diabetes, New Diagnosis>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||6|Yes|No"}}{\fldrslt{\plain\f0\fs22 <<    If Diabetes, New Diagnosis>>}}}}\plain\f0\fs22\par     Difficulty Managing: {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c0036007c005900650073007c004e006f000000}{\*\txfieldtext \plain\f0\fs22 <<    If Diabetes, Difficulty Managing>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||6|Yes|No"}}{\fldrslt{\plain\f0\fs22 <<    If Diabetes, Difficulty Managing>>}}}}\plain\f0\fs22\cell Cardiovascular Disease: {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c0036007c005900650073007c004e006f000000}{\*\txfieldtext \plain\f0\fs22 <<SERVICES: CARDIOVASCULAR DISEASE>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||6|Yes|No"}}{\fldrslt{\plain\f0\fs22 <<SERVICES: CARDIOVASCULAR DISEASE>>}}}}\plain\f0\fs22\par     New Diagnosis: {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c0036007c005900650073007c004e006f000000}{\*\txfieldtext \plain\f0\fs22 <<    If Cardiovascular Disease, New Diagnosis>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||6|Yes|No"}}{\fldrslt{\plain\f0\fs22 <<    If Cardiovascular Disease, New Diagnosis>>}}}}\plain\f0\fs22\par     Difficulty Managing: {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c0036007c005900650073007c004e006f000000}{\*\txfieldtext \plain\f0\fs22 <<    If Cardiovascular Disease, Difficulty Managing>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||6|Yes|No"}}{\fldrslt{\plain\f0\fs22 <<    If Cardiovascular Disease, Difficulty Managing>>}}}}\plain\f0\fs22\b\cf5\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2058\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4611\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6966\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371 Contra-indications\par for Exercise\plain\f0\fs22\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c004c007c007c007c0036007c005900650073007c004e006f000000}{\*\txfieldtext \plain\f0\fs22 <<Contra-indications for Exercise>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|L|||6|Yes|No"}}{\fldrslt{\plain\f0\fs22 <<Contra-indications for Exercise>>}}}}\plain\f0\fs22\par Current Level of Physical Activity\par{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c00310037007c004c006f0077007c004d006f006400650072006100740065007c0048006900670068000000}{\*\txfieldtext \plain\f0\fs22 <<Current level of physical activity>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||17|Low|Moderate|High"}}{\fldrslt{\plain\f0\fs22 <<Current level of physical activity>>}}}}\plain\f0\fs22\cell\cell\cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2058\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4611\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6966\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Clinical \par Indicators\plain\f0\fs22\cell\pard\s16\intbl\sl360\slmult1\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs20 Systolic:  \par Diastolic:  \plain\f0\fs22\cell\plain\f0\fs20 Total Cholestrol:  \par LDL:  \par HDL:  \cell HBA1C:  \par Waist Circumference:  \par Smoking:  \cell\intbl\row\pard\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2058\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Additional Comments\par\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0043007c0030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs22 <<Additional comments>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|C|0||0|"}}{\fldrslt{\plain\f0\fs22 <<Additional comments>>}}}}\plain\f0\fs22\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\par\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clcbpat4\cellx2058\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\cellx3798\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Patient\par Consent\plain\f0\fs22\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs20   \plain\f2\fs28 q\plain\f0\fs20  Yes     \plain\f2\fs28 q\plain\f0\fs20  No\par\plain\f0\fs16\par\plain\f0\fs20   \plain\f2\fs28 q\plain\f0\fs20  Yes     \plain\f2\fs28 q\plain\f0\fs20  No\par\plain\f0\fs22\par\plain\f0\fs20   \plain\f2\fs28 q\plain\f0\fs20  Yes     \plain\f2\fs28 q\plain\f0\fs20  No\par\plain\f0\fs22\cell\plain\f0\fs16 Consent to health professionals visiting me in my home to review my Diabetes and / or CVD management, and providing a report to my GP.\par\par Consent to my GP providing my medical history to health professionals and community service providers involved in my Community Lifestyle Package.\par\par Consent to my Community Lifestyle Package data (after appropriate de-identification) being used for program research and evaluation purposes.\plain\f0\fs22\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2061\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clpadt40\clpadft3\clpadl40\clpadfl3\clpadr40\clpadfr3\clpadb40\clpadfb3\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\plain\f2\fs28 q\plain\f0\fs22\b  Verbal Consent or \plain\f2\fs28 q\plain\f0\fs22\b  Signature: \plain\f0\fs20                                  \plain\f0\fs22\b Date: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Miscellaneous:Date>>{\*\txfieldend}\plain\f0\fs22\par\plain\f0\fs16 The statements above have been read out to the Patient by the Referrer, and the Patient has indicated that they understand the Community Lifestyle Package. The Patient has offered verbal consent and will provide written consent during their Community Lifestyle Package assessment.\plain\f0\fs22\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\plain\f0\fs12\par\plain\f0\fs22\b Medical History {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 5300430059000000}{\*\txfieldtext \plain\f0\fs22 <<Clinical Details:History List>>}{\field{\*\fldinst { HYPERLINK "SCY" }}{\fldrslt{\plain\f0\fs22 <<Clinical Details:History List>>}}}}\plain\f0\fs22\par\plain\f0\fs22\b Medications {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs22 <<Clinical Details:Medication List>>{\*\txfieldend}\plain\f0\fs22\par\trowd\trgaph40\trleft0\trpaddl40\trpaddt40\trpaddr40\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat4\cellx2058\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9966\pard\widctlpar\intbl\pard\s16\intbl\qr\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs22\b\cf5 Attachments\plain\f0\fs22\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs18 Please attach \plain\f0\fs18\b GPMP\plain\f0\fs18  or \plain\f0\fs18\b TCA\plain\f0\fs18  if available.\plain\f0\fs22\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f0\fs12\par\plain\f0\fs16 Argus Summary:\par Patient Name: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs16 <<Patient Demographics:Surname>>{\*\txfieldend}\plain\f0\fs16 , {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs16 <<Patient Demographics:First Name>>{\*\txfieldend}\plain\f0\fs16  DOB: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs16 <<Patient Demographics:DOB>>{\*\txfieldend}\plain\f0\fs16\par Recipient: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs16 <<Addressee:Name>>{\*\txfieldend}\plain\f0\fs16  Date of Report: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs16 <<Miscellaneous:Date>>{\*\txfieldend}\plain\f0\fs12\par\par{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs2 <<PLEASE FILL-IN INDICATORS AND CONSENT>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs2 <<PLEASE FILL-IN INDICATORS AND CONSENT>>}}}}\plain\f0\fs2\par\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par }