REQUEST FOR PREGNANCY CARE CLINIC APPOINTMENT     -FAX 03 4215 1383 
									  -E-REFER USING REFERRAL NET

GP Referral
		Referral Date: Miscellaneous.Date

Feedback Requested:  Yes	

Referral to:
Barwon Health Pregnancy Care (Director of Women's Services, Dr Michael Shembrey)
[ DEPT: PCC ]
Fax: 03 4215 1383

Service requested: Pregnancy Care Clinic
		Referring General Practitioner:
Treating Doctor.Name

Address: Practice.Address
Ph: Practice.Phone
Fax: Practice.Fax
Provider No.: Treating Doctor.Provider Number

Consumer details:
Name: Patient Demographics.Full Name
Date of Birth:.Patient Demographics.DOB
Age:.Patient Demographics.Age
Sex: Patient Demographics.Gender
Title: Patient Demographics.Title
IHI:Patient Demographics.IHI Number

		Contact Address:
Patient Demographics.Full Name
Patient Demographics.Full Address
Tel (H): Patient Demographics.Phone (Home)
Tel (M): Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Alternative Contact: Alternative	

Interpreter required:Interpreter		DVA Number: Patient Demographics.DVA Number	
Preferred language is: Language		Insurance: Patient Demographics.Health Fund Member Number	
Pension Card Number: Patient Demographics.Pension Number		Medicare Number: Patient Demographics.Medicare Number	

Monday Clinic: Monday clinic  		Tuesday Clinic:Tuesday clinic 	
Wednesday Clinic:Wednesday clinic  		Thursday Clinic: Thursday clinic	

HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways
CLINICAL INFORMATION
Reason for patient referral: 
Referral reason	
Gravida: Gravida Para: Para  LNMP: LNMP  EDD: EDD  Estimated gestation: Est gestation
Periconceptual folic acid: Folic acid
First trimester folic acid given? 1st tri folic acid	
CS Hx?: Previous CS?
Number of CS: Number of CS
Risk Factors? Risk factors
Genetic History? Genetic hx	
I am credentialed for the current triennium with BH for shared antenatal care?  I am credentialed 
I am willing to participate in shared antenatal care? Shared care
Why GP shared care is important.  Why GP shared care 
Comment: Comment	
Smoking cessation strategy discussed? Cessation smoking	
Recent PHx Medication list review undertaken: Review PHx meds
Current Medication:
Clinical Details.Medications Current Regular
Allergies: Clinical Details.Allergies
Warnings: Clinical Details.Warnings
	
Social History:
Clinical Details.Social History
Clinical Details.Smoking	
Past Medical History: 
Clinical Details.Problem List (Resolved) With Comments	
Current Medical History:
Clinical Details.Problem List (Current) With Comments	

Investigation Ordered:  (Please CC Pregnancy Care Clinic for all pathology ordered)
Pathology provided by:Pathology Provider	
FBE ordered? FBE 	Blood Goup ordered? Blood grp	
Antibodies? Antibodies	Hepatitis B ordered? Hepatitis B	
Hepatitis C ordered? Hepatitis C	HIV ordered? HIV 	
RPR ordered? RPR	Rubella ordered? Rubella	
Varicella ordered? Varicella	MSU ordered? MSU	
Vitamin D ordered? Vitamin D		
Clinical Details.Result List (Selected)	
Downs syndrome screening discussed? Downs syndrome
	
T1 Screening ordered? T1 Screening 	 US Provider	Date of T1 US	
Dating US ordered? Ultrasound	 US Provider	Date of Dating US	
Morphology US ordered? Morphology US	US Provider	Date of Morphology	
Has Pap smear been performed in last 24/12? Pap smear	US Provider	Date of last pap	
Pap Smears Pap smears	

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