Referral Form
HeartStart Program 
Fax: 4150 1888
Medical Objects: CH4670000QJ

Patient Details:
Name:   <PtFullName>	DOB:   <PtDoB>	
Address:   <PtAddress>	Contact No:   <PtPhoneH>	
NOK:   <NOKName>	Mobile:   <PtPhoneMob>	

Patient Current Medications:
<CurrentRx>

Patient status:
<Stable angina> Stable Angina
<Bypass surgery> Bypass surgery
<Post Infarct> Post Infarct
<Post-stent/Angioplasty> Post-stent/Angioplasty
<Post valve/Function> Post valve/Function
<CHD/Heart Failure> CHD/Heart failure

Identified coronary risk factors:
<Coronary risk factors>

Additional Problems/Other:  <Other>

Functional Assessments:
<Exercise test results enclosed> Recent exercise test results enclosed
<Patient exercise recommended> Exercise tests have not been performed but patient exercise is recommended
Other medical problems which preclude walking as an exercise: <Medical problems precluding walking as exercise> 

Referred by:
<DrDetails>

Date of Referral: <TodaysDate>
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