THS Statewide Antenatal Referral 

All Questions and Headings in Bold MUST BE answered
Referring GP Details	Patient Details	
	Name
Provider No.
Practice

Phone (BH)
Phone (AH)
Fax No.	<DrName>
<DrProviderNo>
<Practice>
<UsrAddress>

<UsrPhone>
<DrMobilePhone>
<UsrFax>
	Name  
Previous Name
Address  
Phone    

THCI No.
IHI 
DOB	<PtFullName>
<Patient previous name (if applicable)>
<PtStreet>, <PtCity>, <PtPostcode>
o (H) <PtPhoneH>	o (W) <PtPhoneWk>
o (M) <PtPhoneMob>	

Please tick preferred contact number and note preferred time to be contacted 
(Between 9am to 4pm, Mon to Fri)

<PtIHI>
<PtDoB>	
	Medicare No.
<PtMCNo>	Ethnicity  <PtEthnicity>
Interpreter Required?  <Interpreter required?>   Language (please specify)  <If interpreter required, which language?>	
	Existing Referral?
oYes	oNo	Perinatal & infant mental health team (south only) 
Referral indicated? oYes	oNo   Referral completed? oYes		oNo  	
Measurements	History	
BP  <BP>	Smoke Hx  <SmkHx>	G <Gravida>   P <Parity>	
Height (cm)  <Height (cm)>	Alcohol Hx  <AlcHx>	EDD (by dates)  <EDCByDate>	
Weight (kg)  <Weight (kg)>		BMI  <BMI>	Drug Hx  <Drug history>	EDD (7-12 week scan result)  <EDCByScan>	
Allergies and other Risk factors	
<Reactions>	

Full Clinical Summary on Page 2. Pre-referral information available at http://www.outpatients.tas.gov.au/

Physical Examination to be performed prior to referral. Completed? oYes	oNo (NB Compulsory in the south prior to referral)
Concerns: 
	
Additional Information (please enter)	

GP Initiated Tests (highlight selection/s and type ‘x’)	Maternity Care Requested	
Required Pre-Referral 
o	Full Blood Count
o Blood Group and Antibodies
o Rubella Titre
o Syphilis serology
o MSU
o Hep B and C serology
o HIV Serology
o	Chlamydia (N, NW)
GDM Screening
o Fasting BSL – no risk factors
o GTT – if risk factors/clinical need 
Perform if clinically indicated
o Vit D
o Hb Electrophoresis 
o TFT
o Chlamydia testing(S)	Aneuploidy Screening/Dating 
(Indicate site of scan and date) 
I have arranged:
o Dating scan (if indicated)
o Aneuploidy Screening counselled 
oDeclined/ oconsented      
o 1st trimester screening 
o 2nd trimester screening
o Non-Invasive Prenatal Testing (NIPT)
	(includes scan) 
Screening tests not consented; I have arranged: 
o Morphology scan 
	Letters indicate regional availability
o	GP Share Care (N, S)
o	Midwives Community Clinic (NW, N, S)
o	KYM/Know your Midwife) (S)
o Midwifery Group Practice (N, NW, S)
o TEAM midwives (N)
o Young Mum's Clinic (S) 
o	Drug & Alcohol Pregnancy Service/ 	Complex Care (S)
o Doctors clinic (N, NW, S)
o Obstetric High Risk Clinic (S)
o Antenatal Endocrine Clinic (N,S)
o Undecided

NB Every effort will be made to accommodate requests where risk assessment is appropriate	
Referring Doctors Signature:                                                                  Date: <TodaysDate>	

Please fax completed form to Women’s and Children’s Clinic:
<Region for referral>

Current Medications	
<SelectedRx>
	
Medical History	
<SelectedPMH>
	
Measurements	

Past Obstetric History	
<ObstetricHx>
	
Psychiatric History, Diagnosis and Medication	

Social History and Family Support	
<FamilyHx>
<SocialHx>
	
Investigations	
<Ix>