Download Acardiac Twin Referral Form

University of Miami/Jackson Memorial Hospital
Fetal Therapy Center
Acardiac Twin Referral Form
PATIENT INFORMATION
,
Name
First
SSN
Address
City
/
DOB (MM/DD/YY)
Last
State
ZIP
E-mail
Employer
Work Phone
-
-
/
-
Phone
-
-
Cell
-
-
Fax
-
-
-
Employer Address
Mother's Maiden Name
Race
Country of Birth
Religion
Marital Status
Emergency Contact/Next of Kin
Phone
-
Relationship
Cell
-
-
-
INSURANCE INFORMATION
Self
Patients relationship to subscriber:
Spouse
Child
Insurance Povider
Other
If other than self: Primary subscriber name?
DOB (MM/DD/YY)
SSN
Policy #
/
-
Group #
/
Insurance Phone
-
-
-
PHYSICIAN INFORMATION
,
Referring Perinatologist
Last
First
Physician Address
City
State
Phone
-
-
Fax
-
-
Phone
-
-
Fax
-
-
ZIP
E-mail
,
Referring Ob/Gyn
Last
First
Physician Address
City
State
ZIP
E-mail
PLEASE SUBMIT BY EMAIL OR PRINT FORM AND FAX TO (305) 357-5675
PLEASE READ BEFORE SUBMISSION:
If using Adobe Acrobat Pro, submit by
email. If using Adobe Reader, please
print the form and fax.
Submit by Email
Print Form
Date (MM/DD/YY)
/
/
FOR UM/JMH FTC USE ONLY:
Date Received (MM/DD/YY)
Recommendation
Acardiac Twin Referral Form - Rev. 8/09
/
/
Diagnosis
Follow Up
Page 1 of 2
MEDICAL INFORMATION
DATE (MM/DD/YY)
AGE
/
/
GRAV
Twins
PARITY
Triplets
LMP
/
Maternal Weight
/
EDC
/
/
GA: weeks
lbs
Placenta
Amniotic Fluid
Placenta is located on which uterine surface:
Maximum vertical pocket in each sac
Anterior
Fundal
Posterior
Amniocentesis
Genetic
Yes
If yes, karyotype
Therapeutic
Yes
Acardiac
cm
Pump twin
cm
Cervical Length
No
46, XX
days
46, XY
Cervical length via
transvaginal ultrasound:
Unk
No
cm
Funneling?
Yes
No
If a therapeutic amniocentesis has been performed,
please provide the following information:
Date
Amount
MM/DD/YY Removed
Fluid
Color
Placenta
Penetrated
Outer Membrane
Detachment
Disruption of
dividing
Membrane
Uterine
Contractions
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Triple Screen
Incompetent Cervix
Is there an increased risk for:
History of an incompetent cervix?
Yes
No
Cerclage in current pregnancy?
Yes
No
Down Syndrome?
Yes
Neural Tube Defect?
Yes
No
No
Fetal Hydrops
Pre-term Labor
Symptoms of pre-term labor?
Yes
No
Yes
No
List symptoms
Medications for pre-term labor
administered?
List medications
Biometry Discordance
Does the pump twin exhibit evidence of:
Ascites
Yes
No
Scalp edema
Yes
No
Pleural effusion
Yes
No
Pericardial effusion
Yes
No
Poor contractility
Yes
No
Measurement of the abdominal circumference (including skin edema)
Acardiac
cm
Pump twin
cm
Medical History
Please list any pertinent medical conditions, including bleeding disorders
How did you hear about us?
Referral
Name?
Medications
Acardiac Twin Referral Form - Rev. 8/09
Website
Insurance provider list
Media
Brochure/flyer/mailing
Other
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