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

<<Miscellaneous:Date>>

Patient	Community Pharmacy	General Practitioner	
<<Patient Demographics:Full Name>>
<<Patient Demographics:Address>>
<<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>
Phone: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
DoB: <<Patient Demographics:DOB>>
Medicare no: <<Patient Demographics:Medicare Number>>
DVA no: <<Patient Demographics:DVA Number>>	DMMR Australia
Email:referrals@dmmraustralia.com.au
Phone: 03 4313 4122
Fax: 03 9960 2787	<<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
E-mail: <<Doctor:E-mail>>
Provider no: <<Doctor:Provider Number>>
Prescriber no: <<Doctor:Prescriber Number>>	

Medical History
<<Clinical Details:History List>>

Current Medications
<<Clinical Details:Medication List>>

Allergies
<<Clinical Details:Allergies>>

Immunisations
<<Clinical Details:Immunisation List>>

Relevant Progress Notes
<<Summary:Progress Notes (Selected)>>

Relevant Pathology Results
<<Summary:Investigation Results (Selected)>>

Measurements
<<Clinical Details:Measurements>>

Social History	Occupation	
<<Clinical Details:Social History>>	<<Patient Demographics:Occupation>>	

Smoking status	Alcohol consumption	
<<Clinical Details:Smoking>>
Quitting stage: <<Clinical Details:Smoking Quitting Stage>>	<<Clinical Details:Alcohol>>	

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

p poor vision
p hearing problems
p swallowing difficulties
p dexterity
p language and/or literacy problems
p cognition
p other: please specify...

Medication Administration

Medication usually administered by <<Medication usually administered by>>	Dosing Aids

p dosing aid device e.g. Dosett, Webster. Specify brand or type...

p other: please specify...

If a dosing aid is used, it is filled by <<Dosing aid, if used, filled by>>	
Disease Monitoring Devices

p peak flow meter
p BP monitor
p blood glucose meter
p INR monitor
p other: please specify...
	Medication Administration Devices

p spacer device for respiratory inhalers
p nebuliser pump for respiratory solutions
p other: please specify...

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
x   the process in having a DMMR; and	THE PATIENT HAS CONSENTED:
x   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.	
THE PATIENT UNDERSTANDS THAT:
x   the location of the DMMR is at <<Patient Demographics:his/her>> choice, but preferably in <<Patient Demographics:his/her>> own home; and the pharmacist who will conduct the DMMR will communicate with me information arising from the DMMR; and	

Signed......................................................................................................   Date <<Miscellaneous:Date>>

<<Doctor:Name>>
<<Doctor:Qualifications>>