Central Queensland Hospital and Health Service Maternity Booking in Referral - Version 02 - 11/2017
Please complete patient contact details in full – to allow us to contact your patient promptly
Patient Details
RE: <PtFullName>
Family Name: <PtSurname>
	Given Names: <PtFirstName> <PtMidName>	
Date of birth:  <PtDoB>
	Home Phone: <PtPhoneH> / <PtPhoneMob>	Work Phone:  <PtPhoneWk>	
Address: <PtAddress>	
Next of kin name: <NOKName>	Phone:<NOKContact>	
Interpreter required?  <Interpreter Required?>	Preferred Language: <Preferred Language>	
Is the woman of Aboriginal or Torres Strait Islander Origin?
<PtEthnicity>
	Is the baby of Aboriginal or Torres Strait Islander Origin?
<Is the baby of Aboriginal or Torres Strait Islander Origin? choose all that apply>

Referral to
To: <Specialist Name>	Service: <CQHHS Maternity Service>
	Fax: <Fax Number>
	
Referring Clinician’s Details
From: <DrName>
	Phone: <DrPhone>	Fax: <DrFax>	
Address: <DrAddress>
	
Provider Number: <DrProviderNo>	Email: <DrEmail>	

Clinical Details
Date of first ANTENATAL visit: <Date of first antenatal visit>
	GP willing to provide shared care:  <GP willing to provide shared care:>     	
LNMP: <LMP> Certain? <Certain of LNMP?>	EDD: <EDC>	Last pap smear: <Last Pap Smear>	BMI: <BMI>
	
Dating Scan (if required): 	Discussed?	<Dating Scan Discussed?>	
	Ordered?	<Dating Scan Ordered?>	
Nuchal translucency plus first trimester serum screen (11-13 weeks +6days):	Discussed?	<Nuchal translucency plus first trimester serum screen discussed?>	
	Ordered?	<Nuchal translucency plus first trimester serum screen ordered?>	
Chorionic Villus Sampling (CVS)  <Chorionic Villus Sampling OR> OR 
Amniocentesis <Amniocentesis>	Discussed?	<Choose tests discussed with patient>	
	Ordered?	<Choose tests ordered>	
Morphology diagnostic ultrasound (18-20weeks): 	Discussed?	<Morphology diagnostic ultrasound (18-20weeks) discussed?>	
	Ordered?	<Morphology diagnostic ultrasound (18-20weeks) ordered?>	
Routine antenatal tests ordered at: (please send copies with referral)  <Routine antenatal tests ordered at: (please send copies with referral) :>	
Significant obstetric history:   <ObstetricHx>
Gravida:  <Gravida>   Para:  <Para>   M/C:  <M/C>    Ectopic: <Ectopic>   TOP: <TOP>	
Significant medical/surgical history: <SelectedPMH>	
Medication list: <SelectedRx>	
Allergies: <Reactions>	
Smoking status: <SmkStatus>      <Cigarettes / day> cigs/day	Alcohol: <AlcHx>      <Drinks / day> drinks/day	
Warnings and alerts: <Warnings and Alerts>	
Other comments: (e.g. social concerns) <Other comments (e.g.social concerns)>	
Referring Clinician’s signature:	Date: <FormattedDate>