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: <PtSurname>	Given Names: <PtFirstName> <PtMidName>
	
DOB: <PtDoB>	Date of Referral: <TodaysDate>	
Address: <PtAddress>	
Phone (H): <PtPhoneH>	Phone (W): <PtPhoneWk>	Phone (M): <PtPhoneMob>	
Aboriginal and or Torres Strait Islander Status: <Aboriginal and or Torres Strait Islander Status:>

Aboriginal Health Service and Contact: <Aboriginal Health Service and Contact:>	Culturally and Linguistically Diverse? <Culturally and Linguistically Diverse?>
Country of Birth: <Country of Birth:>

Interpreter required?<Interpreter required?>
If Yes, what language? 
	
Medicare card no: <PtMCNo>	Medicare expiry date: <PtMCExpiry>	
REFERRER'S DETAILS	
Name: <UsrName>	Provider number: <DrProviderNo>	
Organisation/practice name: <Practice>	Address: <UsrAddress>	
 Phone: <UsrPhone>	 Fax: <UsrFax>	 Signature: 	
PATIENT ASSESSMENT QUESTIONNAIRE	
1. Patient symptoms (i.e.pain, vaginal discharge, bowel/bladder concerns) <Patient symptoms (i.e.pain, vaginal discharge, bowel/bladder concerns)>	
2. How long has the patient reported having symptoms? <How long has the patient reported having symptoms (weeks/months/years)>    weeks/month/years 	
3. What has the patient identified makes their symptoms worse? <What has the patient identified makes their symptoms worse?>	
PATIENT EXAMINATION FINDINGS	
(i.e. vaginal, MC&S – urine, LVS, Ultrasound)

<Ix> 	

MENTAL HEALTH	
4. How would the patient describe their mood most of the time for the last 3 months? <How would the patient describe their mood most of the time for the last 3 months?>

	
GYNAECOLOGICAL SURGERY	
5. Note any relevant gynaecological surgery, including details of mesh implants (if known). 
<Note any relevant gynaecological surgery, including details of mesh implants (if known).>	
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. 
<SelectedRx>	
DIAGNOSTICS	
8. Please attach any relevant patient PATHOLOGY REPORT and MR/ULTRASOUND REPORT.
(or cc the Pelvic Mesh Clinic in on the Ultrasound report) 	
SEXUAL INTERCOURSE	
9. Does the patient Complain of pain with sexual intercourse? <Does the patient complain of pain with sexual intercourse?>	
10. Does the patient report that their sexual partner complains of pain with intercourse <Does the patient report that their sexual partner complains of pain with intercourse>	
QUALITY OF LIFE	
11. Has the patient had to reduce work hours/duties due to their pain/symptoms? <Has the patient had to reduce work hours/duties due to their pain/symptoms?>	
12. In an average month how many days has the patient reported pain? <In an average month how many days has the patient reported pain?> /month	
13. What is the patient's pain score on average? <What is the patient's pain score on average?>	
14. On a scale of 1-10 describe how the patient's pain has interfered with the following areas of their life: (circle as appropriate) for example 0 = No interference and 10 = completely interferes	
General day to day activities - <On a scale of 1-10 describe how the patient's pain has interfered with the following areas of their life: General Day to Day activities>	
Patient's mood - <On a scale of 1-10 describe how the patient's pain has interfered with the following areas of their life: Patients Mood>	
Patient's ability to walk - <On a scale of 1-10 describe how the patient's pain has interfered with the following areas of their life: Patient's ability to walk>	
Patients relationships with other people - <On a scale of 1-10 describe how the patient's pain has interfered with the following areas of their life: Patients relationships with other people>	
Patient's sleep - <On a scale of 1-10 describe how the patient's pain has interfered with the following areas of their life: Patient's Sleep>	

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