Referring Health Professional Email *Please allocate the email that will be the best point of contact for us to send reports and other client based correspondence to.

Date of referral *

Referral Organisation

Participant Details

Title *

Name *First and Last Name here please. Our clinical software does not recognize (in bracket names). Please type in legal name.

Date of Birth *

Preferred name

Phone number *

Address *

Primary / Emergency Contact

Name *

Phone number *

Is the primary contact the person we call to book appointments? *

YesNo

Referral Information

Reason for referral *Why have you identified this client as being suitable for the Healthy Ageing - Early Intervention program with Summit Health Solutions.

Client Medical History *Medical history impacting on clients mobility and independence which supports this referral.

GP Name *

GP Clinic Phone *

GP Clinic Name and Address *

Client PersonalityAny anxiety, mood changes, threatening behavior. This is for the safety of Summit Health Staff

Pre-Frailty Screening

Thank you for referring your patient to the Summit Strong Program. The following information assists our team in understanding the participant's current health, frailty risk, and functional status, helping us determine program suitability, support appropriate triage, and establish baseline measures for outcome evaluation.

FRAIL SCALE RISK ASSESSMENT - Prof John Morley

Please provide the participant's most recent FRAIL Scale score, if available. This helps us assess frailty risk, understand referral rationale, and establish a baseline for the Summit Strong Program.
Complete the below table based on your clients answers.

FATIGUE

All or most of the timeSome, a little or none of the time

How much of the time during the past 4 weeks did you feel tired?

All or most of the timeSome, a little or none of the time

RESISTANCE

YesNo

In the last 4 weeks by yourself and not using aids, do you have any difficulty walking 10 steps without resting?

YesNo

AMBULATION

YesNo

In the last 4 weeks by yourself and not using aids, do you have any difficulty walking 300 meters OR around one block?

YesNo

ILLNESS:

Did your Doctor ever tell you that you have:

Hypertension
Diabetes
Cancer (not skin cancer)
Chronic Lung disease
Asthma
Heart attack
Congestive heart failure
Angina
Arthritis
Kidney disease
Stroke or Parkinson's Disease

Illness calculation *

Yes to 0-4 clinical conditionsYes to 5-11clinical conditions

LOSS OF WEIGHT

YesNo

Have you unintentionally lost more than 5kg or 5% of your body weight in the past year?

YesNo

Scoring:ROBUST = 0, PRE-FRAIL = 1-2, FRAIL = 3-5

PROMIS 29+2 pre program score

As part of the ACT PHN / Capital Health Network Healthy Aging - Early Intervention Summit Strong Program requirements, participants will complete the PROMIS-29 +2 assessment to help measure physical, mental and social wellbeing outcomes throughout the program.

If you have previously completed a PROMIS-29 +2 assessment with this patient, please provide any available information below.

Promis 29+ Date completed

Raw Score

T-Score

Pre-Frailty Screening Measures

Please provide any recent TUG, 5xSTS, 4-Metre Walk Test and Grip Strength results. These measures help us understand how the participant was identified for referral, assess frailty risk, and establish a baseline for the Summit Strong Program.

(1) Five times sit to stand test (5xSTS) in seconds> or 11 seconds = low muscle strength and function

(2) Handgrip strength in kgIndividuals over 65 years old, the Australian standard criteria for low grip strength (indicating probable sarcopenia) Men <27 and Women <16

(3) 4 Metre Walk Test (Gait Speed) in m/sGait speed in (m/s). Gait speed of longer than 5 seconds to walk 4 metres (<0.8 m/s) suggests an increased risk of frailty

(4) Timed up and go (TUG) in secondsRecording in seconds: An older adult who takes ≥12 seconds to complete the TUG is at risk for falling

Hospital Admissions or Emergency Department Presentations

Hospital admissions and Emergency Department presentations are recognised indicators of frailty, declining function, and health instability in older adults. Tracking these outcomes before and after participation helps Summit Strong evaluate its effectiveness in supporting healthy ageing, maintaining independence, and reducing avoidable healthcare utilisation. Please record below to the best of your knowledge.

Hospital Admissions over the last 12 weeks *

YesNoUnsure

Emergency Department Presentations over the past 12 weeks *

YesNoUnsure

How many hospital admissons and why?

How many times and why?

Supporting Docs if required

Browse

Communication details

Is this client considered CALD origin

YesNoUnknown

Is a translator required?

Yes - a next of kin is able to translate or Client will require translator (Please provide no. of the NOK or Translator)No

Note: Summit health Solutions does not provide translator at the moment.

Is this client Aboriginal or Torres Strait Islander origin?

NoYes, Aboriginal Yes, Torres Strait Islander

What language is required

Completion of referral form

Name of Referring Person *

Signature *

Draw signature|Type signatureClear

Thank you for sending us this referral.

We look forward to working with your client soon.