<<Miscellaneous:Practice Letterhead>>
  
REVIEW GP MANAGEMENT PLAN/TEAM CARE ARRANGEMENTS	

Patient’s Name: <<Patient Demographics:Full Name>>
Date of Birth:  <<Patient Demographics:DOB (long)>>
Medicare No:  <<Patient Demographics:Medicare Number>> <<Patient Demographics:Medicare Expiry Date>>
Address: <<Patient Demographics:Full Address>>
Tel (Home): <<Patient Demographics:Phone (Home)>>
Tel (Mobile): <<Patient Demographics:Phone (Mobile)>>	 Details of Patient’s Usual GP:
Name: <<Doctor:Name>>
Practice Address:  <<Practice/Location:Name>>
Address:  <<Practice/Location:Address>>
Phone: <<Practice/Location:Phone>>
Fax: <<Practice/Location:Fax>>
Provider No: <<Doctor:Provider Number>>	

PAST MEDICAL HISTORY:
<<Clinical Details:History List>>

FAMILY HISTORY:
<<Clinical Details:Family History>>

SOCIAL HISTORY:
<<Clinical Details:Social History>>

MEDICATIONS:	
<<Clinical Details:Medication List>>

ALLERGIES/ADVERSE REACTIONS:  
<<Clinical Details:Allergies/Adverse Reactions>>

IMMUNISATIONS:	
<<Clinical Details:Immunisation List>>

SMOKING:	
<<Clinical Details:Smoking>>
<<Clinical Details:Smoking Quitting Stage>>

ALCOHOL:
<<Clinical Details:Alcohol>>

PROGRESS NOTES:
<<Summary:Progress Notes (Selected)>>

Date service was completed:  <<Miscellaneous:Date (long)>>	Next Review Date:  3 months	

GP’s Signature:  x_______________________________________________	Date: <<Miscellaneous:Date (long)>>

INVESTIGATIONS:
<<Summary:Investigation Results (Selected)>>