Central Queensland Hospital  and Health Service

Early Pregnancy Assessment Service
(EPAS)
REFERRAL

Facility / Unit:  Rockhampton Hospital	(Affix identification label here)
URN: 
Family name: <<Patient Demographics:Surname>>
Given Name(s): <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>
Address: <<Patient Demographics:Address>>
Phone - Home: <<Patient Demographics:Phone (Home)>> Work: <<Patient Demographics:Phone (Work)>> Mobile: <<Patient Demographics:Phone (Mobile)>>
Date of birth: <<Patient Demographics:DOB>>         Sex: <<Patient Demographics:Gender>>	
Date of referral: <<Miscellaneous:Date (short)>>
GP Name: <<Doctor:Name>>         Provider No: <<Doctor:Provider Number>>
GP Practice: <<Practice:Name>>
Referral to: 	
Regular periods (Y/N): 	LNMP: 	Gestation:        /40	
Pregnancy confirmed by: 	Urine test (Y/N): 	BhCG (Y/N): 	USS (Y/N): 	
Blood group + Antibodies and BhCG collected (Y/N): 	Blood group: 	
USS attended/booked (Y/N): 	Result: 	
	
Criteria
Less than 20 weeks gestation (Y/N): 
Clinically stable with (Y/N): 
     - Threatened miscarriage (Y/N): 
     - Ectopic pregnancy (Y/N): 
     - Pregnancy of unknown location (PUL): 
     - Non-viable pregnancy/Fetal demise -USS (Y/N): 
     - Missed miscarriage (Y/N): 
Other: 
	Relevant history: G:     P:     M:     T: 
Previous STI / PID (Y/N): 
Previous pelvic surgery (Y/N):  
Endometrioses (Y/N): 
Contraceptive use (Y/N): 
Smoking (Y/N): 	
Please send signed referrals to FAX: (07) 4920 6862
EPAS information given to patient (Y/N): 
For any further enquiries ring EPAS on (07) 4920 6438 or email EPAS.Rockhampton@health.qld.gov.au	
Referrer Name: <<Doctor:Name>>                         Designation: <<Doctor:Qualifications>>
Signature:                                                          Date: <<Miscellaneous:Date (short)>>