Referral for Domiciliary Medication Management - Home Medicines Review
Medical Benefits Schedule Item 900. Also known as DMMR or HMR

<TodaysDate>

Patient	Community Pharmacy	General Practitioner	
<PtFullName>
<PtStreet>
<PtCity> <PtState> <PtPostcode>
Phone: <PtPhoneH>
Mobile: <PtPhoneMob>
DoB: <PtDoB>
Medicare no: <PtMCNo>
DVA no: <PtDVANo>	DMMR Australia
Email:referrals@dmmraustralia.com.au
Phone: 	03 4313 4122
Fax: 	03 9960 2787	<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:
<I HAVE EXPLAINED TO THE PATIENT the process in having a DMMR>    the process in having a DMMR; and

THE PATIENT UNDERSTANDS THAT:
<THE PATIENT UNDERSTANDS THAT the location of the DMMR is at their choice, but preferably in their own home>    the location of the DMMR is at <HisHerTheir> choice, but preferably in <HisHerTheir> own home; and
the pharmacist who will conduct the DMMR will communicate with me information arising from the DMMR; and	THE PATIENT HAS CONSENTED:
<THE PATIENT HAS CONSENTED to sharing their medical history, medications, and Medicare or DVA number for pharmacist payment purposes, and to their information being shared with DMMR Australia, whose administrative support staff may include overseas personnel.>  to sharing their medical history, medications, and Medicare or DVA number for pharmacist payment purposes, and to their information being shared with DMMR Australia, whose administrative support staff may include overseas personnel.	

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

<DrName>
<DrQualifications>