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PT ID SURNAME: THS – NORTH WEST INTEGRATED MATERNITY SERVICES GP Referral to Antenatal Clinic DOB: OTHER NAMES: ADDRESS: All questions and headings in yellow MUST BE answered Referring GP Details Patient Details (from GP records) Date: Name: <<Miscellaneous:Date>> <<Doctor:Name>> Prov. No.: <<Doctor:Provider Number>> Practice: <<Practice:Name>> Address: <<Doctor:Address Line 1>> <<Doctor:Address Line 2>> <<Doctor:City>> <<Doctor:Postcode>> Phone (BH): <<Doctor:Phone>> Fax: <<Doctor:Fax>> Appointment Urgency (highlight selection and type ‘x’) Urgent (within 2 wks), Normal (First apt at approx 10 wks gestation> Surname: <<Patient Demographics:Surname>> Given Name(s): <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>> Previous Name: DOB: <<Patient Demographics:DOB>> Address: <<Patient Demographics:Address Preferred Line 1>> <<Patient Demographics:Address Preferred Line 2>> <<Patient Demographics:Address Preferred City>> <<Patient Demographics:Address Preferred Postcode>> Contact: (h) <<Patient Demographics:Phone (Home)>> (w) <<Patient Demographics:Phone (Work)>> (m) <<Patient Demographics:Phone (Mobile)>> Preferred contact: Sex: <<Patient Demographics:Sex>> Marital Status: <<Patient Demographics:Marital Status>> Medicare No: <<Patient Demographics:Medicare Number>> Concession No: <<Patient Demographics:Pension Number>> Ethnicity: <<Patient Demographics:Ethnicity>> Interpreter requ. <<Interpreter required?>> (if yes) language: <<If interpreter required, which language?>> Measurements BP: <<BP>> Height: Weight: BMI: <<Height>> <<Weight>> <<BMI>> Gravida and Parity Gravida: <<Clinical Details:Gravida>> Parity: <<Clinical Details:Parity>> EDD (7-12 wk scan result): <<EDC by scan>> LNMP: <<LNMP>> Cycle length: <<Cycle length>> Cycle Regularity: <<Cycle regularity>> History Smoking Hx: Alcohol Hx: <<Clinical Details:Smoking>> <<Clinical Details:Alcohol>> Allergies and other Risk Factors: Allergies: <<Clinical Details:Allergies/Adverse Reactions>> Warnings/comments: <<Clinical Details:Warnings>> Additional Information (eg social issues, special needs, IVF, illicit drug use, requests shared care) <<Additional Info (eg social, special needs, IVF, illicit>> Please fax completed form to North West Integrated Maternity Service Nurse Unit Manager Fax: 1800 027 538 Phone: 647 85180 OFFICE USE CLINIC DATE TIME ONLY Key: BMI = Body Mass Index BP = Blood Pressure EDD = Estimated Due Date HIV = Human Immunodeficiency Virus Kg = Kilograms MSU = Midstream Urine RPR = Rapid Plasma Reagin TSH = Thyroid-Stimulating Hormone Template revised by Primary Health Tasmania – MD – May 2017 Page 1 GP Initiated Tests Required Pre-Referral (highlight selection/s and type ‘x’) Full Blood Count Optional Tests (Assess Risk/Need) Maternity Care Requested 1st trimester screening 2nd trimester screening Varicella TSH <<Maternity Care Requested (choose one)>> Blood Group and Antibodies Rubella Titre RPR Vitamin D Hep B Hep C HIV Ferritin Chlamydia MSU Dating scan is arranged (after 7 wks gestation) <<Dating scan is arranged (after 7 wks gestation)>> Highly Recommended Actions Antenatal Care Site Folic Acid supplement <<Antenatal Care Site (choose one)>> Flu vaccination Current Medications <<Clinical Details:Medication List>> Medical History <<Clinical Details:History List>> Past Obstetric History <<Clinical Details:Past Obstetric History>> Mental Health History, Diagnosis and Medication <<Mental Health History, Diagnosis and Medication>> Social History and Family Support <<Clinical Details:Social History>> <<Clinical Details:Family History>> Investigation Results <<Summary:Investigation Results (Selected)>> Template revised by Primary Health Tasmania - MD - May 2017 - Patient Name: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>> Page 2
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