Process - Physician - Fraser Health Authority

MEDICAL/PHYSICAL/PSYCHIATRIC:Current Mental State (include auditory hallucinations, delusions, paranoid, etc.)Details of Current Problems:Medical/Physical Problems::Diet: (for CRESST)Medication Coverage:ID Number: Plan G Regular Income Assistance PWD* PWMB** Veteran Affairs Aboriginal Status Extended Medical SelfInjection: Yes No Date Last Given:Name, Dose, Frequency:Medications:Allergies/Adverse Effects (medication, environment, food)Has there been Recent Change to Meds?: Yes No Is the Individual Med Compliant? Yes NoNot Applicable to CRESSTCertified: Y NOn Extended LeaveCertified: Y NOriginal Certificate(s) sent to:Copies of Extended Leave sent to:SPECIFIC INSTRUCTIONS/REQUESTS (use extra sheet if necessary, but be sure to fax ALL information)Placement Plan: (Where will the client go from CRESST?)FOR CRESST: A two (2) week prescription for all medical, psychiatric and over the counter medication, including smokingcessation aids if applicable, is required (i.e. new Rx, written or phoned into CRESST).* PWD = Person with Disability** PWMB = Person with Multiple Barriers07/09 C:\Users\Bruce\Documents\MD-DOC\PSP\Mental Health\Fraser Valley\Cresst referral.doc2