Referral for Domiciliary Medication Management - Home Medicines Review (DMMR or HMR)
Medical Benefits Schedule Item 900

<TodaysDate>

Patient	Community Pharmacy	General Practitioner	
<PtFullName>
<PtStreet>
<PtCity> <PtState> <PtPostcode>
Phone: <PtPhoneH>
DoB: <PtDoB>
Medicare no: <PtMCNo>
DVA no: <PtDVANo>	Better Health HMR
Email: betterhealthhmr@gmail.com
Phone: 	0447004705	<DrName>
<Practice>
<UsrAddress>
Phone:	<UsrPhone>
Fax: 	<UsrFax>
E-mail: 	<DrEmail>
Provider no: <DrProviderNo>
Prescriber no: <DrPrescriberNo>	

Medical History
<PMHActive>

Current Medications
<CurrentRx>

Allergies
<Reactions>

Immunisations
<Imm>

Relevant Progress Notes
<Visits>

Relevant Pathology Results
<Ix>

Measurements
<Observations>

Social History	Occupation	
<SocialHx>	<PtOccupation>	

Smoking status	Alcohol consumption	
<SmkStatus>
Quitting stage: <SmkHx>	<AlcHx>	

Reason for referral for DMMR	Issues that may influence medication use	
<Reason for referral 1>

<Reason for referral 2>

<Reason for referral 3>	To select any item - highlight its checkbox and type x
<Issues that may influence medication use>
<Poor vision> poor vision
<Hearing problems> hearing problems
<Swallowing difficulties> swallowing difficulties
<Dexterity> dexterity
<Language and/or literacy problems> language and/or literacy problems
<Cognition> cognition
<Other issues (please specify):> other: <Issues that may influence medication use: Other>

Medication Administration

Medication usually administered by <Medication usually administered by>	Dosing Aids
<Dosing Aids>
<dosing aid device e.g. Dosett, Webster> dosing aid device e.g. Dosett, Webster. Specify brand or type: <Dosing Aid Device: specify brand or type:>

<other dosing device> other: <Please specify if other dosing device:>

If a dosing aid is used, it is filled by <Dosing aid, if used, filled by>	
Disease Monitoring Devices
<Disease Monitoring Devices>
<Peak flow meter> peak flow meter
<BP monitor> BP monitor
<blood glucose meter> blood glucose meter
<INR monitor> INR monitor
<Other devices (please specify) :> other: <Disease Monitoring Devices: Other>
	Medication Administration Devices

<Spacer device for respiratory inhalers> spacer device for respiratory inhalers
<Nebuliser pump for respiratory solutions> nebuliser pump for respiratory solutions
<Other devices (please specify):> other: <Medication Administration Devices: Other>

The patient <Speaks enough English to do the interview> English to do the interview.

An interpreter <An interpreter (is/is not) required> required. The patient's preferred language is <The patients preferred language is>.

I HAVE EXPLAINED TO THE PATIENT
ξ   the process in having a DMMR; and	THE PATIENT HAS CONSENTED:
ξ   to me releasing to you information about <HisHerTheir> medical history and medications; and	
THE PATIENT UNDERSTANDS THAT:
ξ   the location of the DMMR is at <HisHerTheir> choice, but preferably in <HisHerTheir> own home; and
ξ   the pharmacist who will conduct the DMMR will communicate with me information arising from the DMMR; and	THE PATIENT <Consent to release Medicare/ DVA  Number details>:
ξ   to me releasing <HisHerTheir> Medicare no. or DVA no. to you for the pharmacist's payment purposes.
 THE PATIENT HAS CONSENTED
ξ   to me releasing <HisHerTheir> information to Better Health HMR.	

Signed......................................................................................................   Date: <TodaysDate>

<DrName>
<DrQualifications>