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Patient Information Surname Patel
First Name Alisha
DOB 1987-04-12
Gender Female
HN 1234567890
HN VC AB

Address 2453 Dundas St W
Address Line 2 Apt 708
City Toronto
Province ON
Postal Code M6P 1X3

Mobile # 416-555-0198
Home # 416-555-0131
Email alisha.patel87@example.com
[Optional] Additional Patient Information Sex assigned at birth Female
Pronouns She/HerThey/Them
Preferred language Other
Specify Urdu
Translator required Yes
Best method of contact MobileHomeBusiness
Voicemails acceptable Yes

Alternate contact Yes
Name Imran Patel
Alternate contact phone # 416-555-0144
Relationship Spouse
Is Alternate contact the appointment booking contact? Yes

Accessibility concerns or disability Yes
Specific Wheelchair
Special considerations Yes
Details of special considerations Patient has significant anxiety in medical settings. Please explain steps in advance; prefers a quiet waiting area when possible.

Send copies of reports to additional providers Yes
Name(s) Dr. Farah Alvi (Endocrinology)
Contact information Fax 416-555-0187
Referral Details Triage Considerations Requested Priority Urgent
Reason for urgent triage Progressive exertional chest tightness with reduced exercise tolerance over the past 3 weeks.

Name of the suspected diagnosis/problem triggering referral New exertional chest tightness; rule out stable angina / ischemic heart disease.

Brief Description of Referral, History, Management, and Investigations 38F with 3-month history of exertional substernal chest tightness when climbing stairs, relieved by rest in 3–5 minutes. No syncope. Occasional palpitations. Risk factors: type 2 diabetes (A1c 7.6%), hypertension, dyslipidemia, strong family history (father MI at 52). Vitals today: BP 146/92, HR 82. Physical exam unremarkable. Baseline ECG in clinic: normal sinus rhythm, no acute ischemic changes. Started ASA 81 mg daily and optimized statin (rosuvastatin 20 mg).
Preferred Consultant or Location Preferred consultant or location Yes
Please specify either a preferred consultant or location
Consultant Dr. Samantha Chen
Location Toronto General Hospital – Cardiology Clinic
Patient willing to travel for shorter wait time Yes
Other Prefers weekday mornings; relies on translator services.
Referrer's Information Site Name Parkdale Family Health Team
Address (Line 1) 123 Brock Ave
Address (Line 2) Suite 401
City Toronto
Province ON
Postal Code M6K 2L5
Phone # 416-555-0101
Fax # 416-555-0102
Professional ID 7654321
Signed Dr. Nadia Rahman, MD CCFP
Role Physician Assistant
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Please explain steps in advance; prefers a quiet waiting area when possible." } ] }, { "linkId": "additionalinfo_sendcopiestoadditionalproviders", "text": "Send copies of reports to additional providers", "answer": [ { "valueCoding": { "display": "Send copies of reports to additional providers" } } ] }, { "linkId": "additionalinfo_sendcopiestoadditionalproviders_names", "text": "Name(s):", "answer": [ { "valueString": "Dr. Farah Alvi (Endocrinology)" } ] }, { "linkId": "additionalinfo_sendcopiestoadditionalproviders_contactinfo", "text": "Contact information:", "answer": [ { "valueString": "Fax 416-555-0187" } ] } ] }, { "linkId": "274716928898", "text": "Referral Details", "item": [ { "linkId": "836886186557", "text": "Triage Considerations", "item": [ { "linkId": "referral_requestedpriority", "text": "Requested Priority:", "answer": [ { "valueCoding": { "system": "http://hl7.org/fhir/request-priority", "code": "urgent", "display": "Urgent" } } ] }, { "linkId": "referral_requestedpriority_urgentreason", "text": "Reason for urgent triage:", "answer": [ { "valueString": "Progressive exertional chest tightness with reduced exercise tolerance over the past 3 weeks." } ] } ] }, { "linkId": "200848944281", "text": "Name of the suspected diagnosis/problem triggering referral:", "answer": [ { "valueString": "New exertional chest tightness; rule out stable angina / ischemic heart disease." } ] }, { "linkId": "602158378622", "text": "Brief Description of Referral, History, Management, and Investigations", "answer": [ { "valueString": "38F with 3-month history of exertional substernal chest tightness when climbing stairs, relieved by rest in 3–5 minutes. No syncope. Occasional palpitations. Risk factors: type 2 diabetes (A1c 7.6%), hypertension, dyslipidemia, strong family history (father MI at 52). Vitals today: BP 146/92, HR 82. Physical exam unremarkable. Baseline ECG in clinic: normal sinus rhythm, no acute ischemic changes. Started ASA 81 mg daily and optimized statin (rosuvastatin 20 mg)." } ] } ] }, { "linkId": "preferredconsultlocation_header", "text": "Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.", "item": [ { "linkId": "preferredconsultlocation_selector", "text": "Preferred consultant or location", "answer": [ { "valueCoding": { "display": "Preferred consultant or location" } } ] }, { "linkId": "preferredconsultlocation_specify", "text": "Please specify either a preferred consultant or location", "item": [ { "linkId": "preferredconsultlocation_consultant", "text": "Consultant:", "answer": [ { "valueString": "Dr. Samantha Chen" } ] }, { "linkId": "preferredconsultlocation_location", "text": "Location:", "answer": [ { "valueString": "Toronto General Hospital – Cardiology Clinic" } ] } ] }, { "linkId": "preferredconsultlocation_willingtotravel", "text": "Patient willing to travel for shorter wait time", "answer": [ { "valueCoding": { "display": "Patient willing to travel for shorter wait time" } } ] }, { "linkId": "preferredconsultlocation_otherconsiderations", "text": "Other considerations:", "answer": [ { "valueString": "Prefers weekday mornings; relies on translator services." } ] } ] }, { "linkId": "referrer_header", "text": "Referrer's Information", "item": [ { "linkId": "referrer_sitename", "text": "Site Name:", "answer": [ { "valueString": "Parkdale Family Health Team" } ] }, { "linkId": "referrer_address_line1", "text": "Address (Line 1):", "answer": [ { "valueString": "123 Brock Ave" } ] }, { "linkId": "referrer_address_line2", "text": "Address (Line 2):", "answer": [ { "valueString": "Suite 401" } ] }, { "linkId": "referrer_address_city", "text": "City:", "answer": [ { "valueString": "Toronto" } ] }, { "linkId": "referrer_address_province", "text": "Province:", "answer": [ { "valueString": "ON" } ] }, { "linkId": "referrer_address_postalcode", "text": "Postal Code:", "answer": [ { "valueString": "M6K 2L5" } ] }, { "linkId": "referrer_phone", "text": "Phone #:", "answer": [ { "valueString": "416-555-0101" } ] }, { "linkId": "referrer_fax", "text": "Fax #:", "answer": [ { "valueString": "416-555-0102" } ] }, { "linkId": "referrer_professionalid", "text": "Professional ID:", "answer": [ { "valueInteger": 7654321 } ] }, { "linkId": "referrer_signature", "text": "Signed:", "answer": [ { "valueString": "Dr. Nadia Rahman, MD CCFP" } ] }, { "linkId": "referrer_role", "text": "Role:", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "449161006", "display": "Physician Assistant" } } ] } ] } ] }