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: <<Patient Demographics:Full Name>>
Family Name: <<Patient Demographics:Surname>>	Given Names: <<Patient Demographics:First Name>>
	
DOB:  <<Patient Demographics:DOB>>	Home Phone: <<Patient Demographics:Phone (Home)>>/ <<Patient Demographics:Phone (Mobile)>>	Work Phone:  <<Patient Demographics:Phone (Work)>>	
Address: <<Patient Demographics:Address>>	
Next of kin name: <<Next of Kin Name>>	Phone: <<Next of Kin phone>>	
Interpreter required?  <<Patient Demographics:Requires Interpreter>>	Language: <<Patient Demographics:Language Preferred>>	
Is the woman of Aboriginal or Torres Strait Islander Origin?
<<Is the woman Aboriginal or Torres Strait Islander?>>
	Is the baby of Aboriginal or Torres Strait Islander Origin?
<<Is baby of Aboriginal or Torres Strait Islander origin?>>	

Referral to
To: <<Specialist Name >>	Service: <<CQHHS Antenatal Service >>	Fax: <<Fax:>>	
Referring Clinician’s Details
From: <<Doctor:Name>>	Phone: <<Doctor:Phone>>	Fax: <<Doctor:Fax>>	
Address: <<Doctor:Address>>
	
Provider Number: <<Doctor:Provider Number>>	Email: <<Doctor:E-mail>>	

Clinical Details
Date of first ANTENATAL visit: <<Date of first antenatal visit>>	GP willing to provide shared care:  <<GP willing to prodvide shared care?>>	
LNMP: <<Clinical Details:LNMP>> Certain? <<LNMP Certain?>>	EDD: <<Clinical Details: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 + 1st tri serum discussed?>>	

Ordered?	
<<Nuchal translucency + 1st tri serum ordered?>>	

Chorionic Villus Sampling (CVS)  <<Chorionic Villus Sampling (CVS) OR>>OR 
Amniocentesis <<Amniocentesis>>	Discussed?	
<<Choose tests discussed with patient>>

Ordered?	
<<Choose tests ordered>>

	
Morphology diagnostic ultrasound (18-20weeks): 	Discussed?	
<<Morphology diagnostic ultrasound discussed?>>	

Ordered?	
<<Morphology diagnostic ultrasound ordered?>>	

Routine antenatal tests ordered at: (please send copies with referral)  <<Routine antenatal tests ordered at: >>	
Significant obstetric history: <<Clinical Details:Past Obstetric History>>
Gravida:  <<Clinical Details:Gravida>>  Para:  <<Clinical Details:Parity>>  M/C: <<M/C>>   Ectopic:  <<Ectopic>> TOP: <<TOP>> 	
Significant medical/surgical history: <<Clinical Details:History List>>	
Medication list: <<Clinical Details:Medication List>>	
Allergies: <<Clinical Details:Allergies/Adverse Reactions>>	
Smoking status: <<Clinical Details:Smoking>> <<Cigarettes / day>>cigs/day	Alcohol: <<Clinical Details:Alcohol>>       <<Drinks / day>>drinks/day	
Warnings and alerts: <<Clinical Details:Warnings>>	
Other comments: (e.g. social concerns) <<Other comments (eg social concerns)>>	
Referring Clinician’s signature:	Date: <<Miscellaneous:Date>>