Pelvic Mesh Patient Referral Form
This questionnaire is to be completed by the Doctor.  It is anticipated the questionnaire will be completed by the Dr in the presence of the patient who should provide the relevant information. 
NB: All fields must be completed to enable processing of referrals.   
  
PATIENT DETAILS	
Family name: Patient Demographics.Surname	Given names: Patient Demographics.First Name	
DOB: Patient Demographics.DOB	Date of referral: Miscellaneous.Date	
Address: Patient Demographics.Address	
Phone (H):Patient Demographics.Phone (Home)	Phone (W): Patient Demographics.Phone (Work)	Phone (M):Patient Demographics.Phone (Mobile)	
Aboriginal and or Torres Strait Islander Status: ATSI Status

Aboriginal Health Service and contact: ATSI Health Service:	Culturally and Linguistically Diverse? Culturally and Lingu

Country of Birth: Country of Birth: 

Interpreter required? Interpreter required
If Yes, What language ?	
Medicare card no: Patient Demographics.Medicare Number	Medicare expiry date: Patient Demographics.Medicare Expiry Date	
REFERRER'S DETAILS	
Name: Miscellaneous.Current User	Provider number: Treating Doctor.Provider Number	
Organisation/practice name: Practice.Name	Address: Practice.Address	
Phone:Practice.Phone	Fax: Practice.Fax	Signature: 	
PATIENT ASSESSMENT QUESTIONNAIRE	
1. Patient symptoms (i.e. pain, vaginal discharge, bowel/bladder concerns)
Pt Assessment 	
2. How long has the patient reported having symptoms?     Reported symptoms  weeks    /    months    /    years   	
3. What has the patient identified makes their symptoms worse?
Symptoms	
PATIENT EXAMINATION FINDINGS	
(i.e. vaginal, MC&S – urine, LVS, Ultrasound)
Examination findings	
MENTAL HEALTH	
4. How would the patient describe their mood most of the time for the last 3 months? Pts Mental Health	
GYNAECOLOGICAL SURGERY	
5. Note any relevant gynaecological surgery, including details of mesh implants (if known).
Gynaecological Surg.	
6. Please attach a copy of the patient's MEDICAL RECORD from the unit where relevant surgery was undertaken, along with a copy of all RELEVANT CORRESPONDENCE from any clinician(s) / specialist(s) that have been involved in the management of this patient. 	
MEDICATIONS	
7. Please attach the PATIENT MEDICATION print out.
Clinical Details.Medication List	
DIAGNOSTICS	
8. Please attach any relevant patient PATHOLOGY REPORT and MR / ULTRASOUND REPORT   
(or cc the Pelvic Mesh Clinic in on the Ultrasound report)  Diagnostics

	
SEXUAL INTERCOURSE	
9. Does the patient complain of pain with sexual intercourse? Sexual Intercourse
10. Does the patient report that their sexual partner complains of pain with intercourse?  Sexual Intercourse	

QUALITY OF LIFE	
11. Has the patient had to reduce work hours/duties due to their pain/symptoms?  Quality of Life	
12. In an average month how many days has the patient reported pain?   Quality of Life / month	
13. What is the patient's pain score on average? Quality of Life	
14. On a scale of 1–10, describe how the patient's pain has interfered in the following areas of their life: (Circle as appropriate) For example, 0 = No interference and 10 = Completely interferes 	
A.	general day-to-day activities Patients Pain 
B.	Patient's mood Patients Pain
C.	Patient's ability to walk Patients Pain
D.	Patient's relationship with other people  Patients Pain
E.	Patients sleep Patients pain	

Please forward this form completed, along with copies of all requested documentation and reports to the:

Attn: Nurse Consultant
Pelvic Mesh Clinic 3E 106.01
Royal Adelaide Hospital
Port Road, Adelaide SA 5000
Fax: (08) 8124 1416
Email: Health.PelvicMeshSupportService@sa.gov.au