Chronic Conditions Programs
Respiratory Linkage Referral Form
Please fax signed referrals to 9201 0033 or email info@blackswanhealthcom.au
Enquiries: 9201 0044
Date of referral: ______________________________
Referrer:
Client details:
 GPSpecialist
Title (Miss, Ms, Mrs, Mr):
Name:
Gender:  Male  Female
Address:
Name:
Phone no:
Address:
Fax no:
Suburb:
Email:
Phone no:
GP Signature:
Email:
DOB:
ELIGIBILITY
 Confirmed respiratory condition



COPD FEV 1% predicted <60% (or multiple hospital admissions/exacerbations due to respiratory condition)
Bronchiectasis (not due to Cystic Fibrosis)
Interstitial Lung Disease
Respiratory Information:
Confirmed respiratory diagnosis: ___________________________________________________________________
Respiratory Physician: ___________________________________________________________________________
Lung Function (attached results preferable)
FEV 1 (L):
FEV 1 (% Pred):
FVC (L)
Other Medical Conditions:
 Hypertension
 Arthritis
 Heart Disease
 Osteoporosis
 Fall/Poor Balance
Other:
 Surgery
 Diabetes
 High Cholesterol
 Epilepsy/Seizures
 Cancer
 Vision Impairment
 Brain/Spinal Injury
 Neurological Disorder
 Fractures
 Asthma
 Chronic Fatigue
 Postural Hypotension
 Smoker
 Chronic Pain >3 months
Current Treatment:
_____________________________________________________________________________________________
Black Swan Health Limited ABN 64169929677
Sanori House, Suites G7, G8 126 Grand Boulevard, Joondalup WA 6027
t: 08 9201 0044 f 08 9201 0033
www.blackswanhealth.com.au
 Oxygen therapy:
Flow rate: _______________ Hours per day: ___________________
 CPAP/ BIPAP
Details: __________________________________________________
Current Medications including related medical condition (or attach):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Allergies:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Referral Process:
Please attach if available:
 GP Management Plan
 Team Care Arrangement
My referrer has explained the purpose of this assessment and program and I give permission to provide and discuss
my medical information with other service providers who are contributing to my care. I understand that my medical
information will remain confidential. Some de-identified data which will not identify me, my Practice or my referrer, may
be used to enable the program to be evaluated. Please note: Information may be accessed by accreditation provider
for accreditation purposes only.
I am aware that I may request a copy of the Black Swan Health Privacy and Confidentiality statement at any time.
Client signature: _____________________________________________________ Date: ___________________
www.blackswanhealth.com.au
t: 08 9201 0044 f 08 9201 0033