VSRF Plus Maternity
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Referral Date: / / GP Referral GP Review Date: / / VSRF+ Maternity Feedback Requested: Yes No
Referral to: Referring General Practitioner (stamp): Name: Address:
Phone: Fax: Email:
Service requested
Patient / client details
Name: Address: Date of Birth: / / Preferred name/s: Phone: Work:
G
Sex: Male Female Mobile: P
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Title: Mr Mrs Ms Miss Email: e
f
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Alternative Contact: r
a
l Indigenous Status:
Reason for patient referral
Other notes (eg current services)
Interpreter required: DVA Number: Preferred language is: Insurance: Pension Card Number: Medicare Number:
Consent to referral and sharing of relevant information: Yes No Attach ‘Patient Consent Form’ if restrictions apply.
Referring doctor: Patient name: Date: / / Page 1 of 2 VSRF+ Maternity
Clinical information
Warnings:
Allergies:
Current Medication: Drug name Ltd. elapse Strength Dose / frequency / special
Social History:
G
P
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S
R
R
e
F
f
e
p
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l
u
a
sl
M
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t
e
Past Medical History: r
n
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t
y
Investigation / Test Results:
Referring doctor: Patient name: Date: / / Page 2 of 2
VSRF+ Maternity
Mother Aboriginal or Torres Strait Islander: Yes No Baby Aboriginal or Torres Strait Islander: Yes No Cultural background: Occupation: Gravida: Para: LNMP: EDD: Estimated gestation: Weight kg: Height cm: BMI:
Risk factors Medical Diabetes before being pregnant Yes No Heart disease - significant Yes No Asthma requiring hospital admissions Yes No BMI >/= 43 Yes No Illicit drug abuse/methadone/buprenorphine Yes No High blood pressure/or on medication Yes No Thyroid disease (uncontrolled) Yes No Blood problems: anaemia, DVT Yes No Epilepsy on treatment Yes No Other:
Obstetric Previous severe Pre-eclampsia Yes No Previous Rhesus isoimmunisation Yes No Parity > 5 babies Yes No Miscarriage/mid trimester loss x3 or more Yes No Previous caesarean / uterine surgery Yes No
V
Significant PPH >/= 1000mls Yes No S
R
Previous small baby <2500g (5lb 8oz) Yes No F
p
l
Previous large baby >4500g (9lb 15oz) Yes No u
s
Multiple pregnancy Yes No M
a
Other: t
e
r
n
i
t I am intending to provide shared antenatal care: Yes No (woman) undecided y
Is the woman a current smoker or has the woman Yes No smoked within the last 12 months? If yes, referral to QUIT or provide smoking cessation assessment, advice and assistance is recommended
Is the partner a current smoker or has the partner Yes No smoked within the last 12 months? If yes, referral to QUIT or provide smoking cessation assessment, advice and assistance is recommended
Referring doctor: Patient name: Date: / / Page 1 of 2
VSRF+ Maternity
Pregnancy investigation / clinical examination checklist: Recommended Blood Group Completed Ordered (Ensure patient brings results)
Antibodies Completed Ordered (Ensure patient brings results)
FBE Completed Ordered (Ensure patient brings results)
Rubella Completed Ordered (Ensure patient brings results) Syphilis Completed Ordered (Ensure patient brings results)
Hep B Completed Ordered (Ensure patient brings results)
HIV/AIDS Completed Ordered (Ensure patient brings results)
Urinalysis/MSU Completed Ordered (Ensure patient brings results)
Morphology ultrasound 18–20 wks Completed Ordered (Ensure patient brings results)
Consider
Ferritin Completed Ordered (Ensure patient brings results)
Thalassaemia Completed Ordered (Ensure patient brings results)
Vitamin D Completed Ordered (Ensure patient brings results)
Hep C Completed Ordered (Ensure patient brings results)
Prenatal aneuploidy screening (1st or 2nd trimester) Completed Ordered (Ensure patient brings results)
Prenatal aneuploidy diagnosis (CVS or Amniocentesis) Completed Ordered (Ensure patient brings results)
Dating ultrasound 10–13 wks Completed Ordered (Ensure patient brings results)
Pap test Completed Ordered (Ensure patient brings results)
Referring doctor: Patient name: Date: / / Page 2 of 2