GP review

Date____________________ GP Name/Practice__________________________________

Patient Name_________________________________________        DOB______________________

Parameter	Result	WAEDOCS criteria 
Indicators that the patient requires inpatient admission	
Height			
Weight (blind, ask the patient to step on the scale backwards)		Loss of >1 kg/week over several weeks OR 
Grossly inadequate nutritional intake (<1000kcal daily) for > 2 days	
BMI		BMI <14	
BSL		< 3.5 mmol/L	
Temperature		< 35.5⁰C	
Lying HR and BP (please make sure the patient has been lying for a full 5 minutes before taking)	HR:

BP:	HR: ≤ 40 bpm (adolescents < 50 bpm) OR >120 bpm or postural tachycardia >20bpm

BP: < 90mmHg systolic or postural blood pressure >10 mmHg drop	
Standing 1 minute	HR:

BP:		
Standing 2 minutes	HR:

BP:		
Standing 3 minutes	HR:

BP:		
ECG		ECG: Any arrhythmia including QTc prolongation, nonspecific ST or T-wave changes including inversion or biphasic waves
	
Na
	K
	Mg
	PO4
	Alb
	LFTs
	Nphils
	Na, K, Mg, PO4 or Albumin:  Below normal range
Liver enzymes: Mildly elevated
Neutrophils: <1.5 × 109/L	
Other WAEDOCS criteria
Psychiatric concerns: Significant psychiatric risk such as deliberate self-harm or suicidal ideation. Moderate-high agitation and/or distress
Purging: Daily (uncontrolled; sufficient to cause distress and/or medical instability)	
Please send to emedss@health.wa.gov.au or fax 92244243