<p> Referral Date: / / GP Referral GP Review Date: / / VSRF+ Maternity Feedback Requested: Yes No</p><p>Referral to: Referring General Practitioner (stamp): Name: Address: </p><p>Phone: Fax: Email: </p><p>Service requested</p><p>Patient / client details</p><p>Name: Address: Date of Birth: / / Preferred name/s: Phone: Work: </p><p>G</p><p>Sex: Male Female Mobile: P</p><p>R</p><p>Title: Mr Mrs Ms Miss Email: e</p><p> f</p><p> e</p><p> r</p><p>Alternative Contact: r</p><p> a</p><p> l Indigenous Status:</p><p>Reason for patient referral</p><p>Other notes (eg current services)</p><p>Interpreter required: DVA Number: Preferred language is: Insurance: Pension Card Number: Medicare Number: </p><p>Consent to referral and sharing of relevant information: Yes No Attach ‘Patient Consent Form’ if restrictions apply.</p><p>Referring doctor: Patient name: Date: / / Page 1 of 2 VSRF+ Maternity</p><p>Clinical information</p><p>Warnings:</p><p>Allergies:</p><p>Current Medication: Drug name Ltd. elapse Strength Dose / frequency / special</p><p>Social History:</p><p>G</p><p>P</p><p>V</p><p>S</p><p>R</p><p>R</p><p> e</p><p>F</p><p> f</p><p> e</p><p> p</p><p> r</p><p> r</p><p> l</p><p> u</p><p> a</p><p> sl</p><p>M</p><p> a</p><p> t</p><p> e</p><p>Past Medical History: r</p><p> n</p><p> i</p><p> t</p><p> y</p><p>Investigation / Test Results:</p><p>Referring doctor: Patient name: Date: / / Page 2 of 2</p><p>VSRF+ Maternity</p><p>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: </p><p>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: </p><p>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</p><p>V</p><p>Significant PPH >/= 1000mls Yes No S</p><p>R</p><p>Previous small baby <2500g (5lb 8oz) Yes No F</p><p> p</p><p> l</p><p>Previous large baby >4500g (9lb 15oz) Yes No u</p><p> s</p><p>Multiple pregnancy Yes No M</p><p> a</p><p>Other: t</p><p> e</p><p> r</p><p> n</p><p> i</p><p> t I am intending to provide shared antenatal care: Yes No (woman) undecided y</p><p>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</p><p>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</p><p>Referring doctor: Patient name: Date: / / Page 1 of 2</p><p>VSRF+ Maternity</p><p>Pregnancy investigation / clinical examination checklist: Recommended Blood Group Completed Ordered (Ensure patient brings results)</p><p>Antibodies Completed Ordered (Ensure patient brings results)</p><p>FBE Completed Ordered (Ensure patient brings results)</p><p>Rubella Completed Ordered (Ensure patient brings results) Syphilis Completed Ordered (Ensure patient brings results)</p><p>Hep B Completed Ordered (Ensure patient brings results)</p><p>HIV/AIDS Completed Ordered (Ensure patient brings results)</p><p>Urinalysis/MSU Completed Ordered (Ensure patient brings results)</p><p>Morphology ultrasound 18–20 wks Completed Ordered (Ensure patient brings results)</p><p>Consider</p><p>Ferritin Completed Ordered (Ensure patient brings results)</p><p>Thalassaemia Completed Ordered (Ensure patient brings results)</p><p>Vitamin D Completed Ordered (Ensure patient brings results)</p><p>Hep C Completed Ordered (Ensure patient brings results)</p><p>Prenatal aneuploidy screening (1st or 2nd trimester) Completed Ordered (Ensure patient brings results)</p><p>Prenatal aneuploidy diagnosis (CVS or Amniocentesis) Completed Ordered (Ensure patient brings results)</p><p>Dating ultrasound 10–13 wks Completed Ordered (Ensure patient brings results)</p><p>Pap test Completed Ordered (Ensure patient brings results)</p><p>Referring doctor: Patient name: Date: / / Page 2 of 2</p>