OBSTETRIC REFERRAL - THE CANTERBURY HOSPITAL
Low Risk Women - Woman to bring completed form to the hospital with relevant screening results
High Risk Women requiring Early or Urgent assessment please fax to 9787 0431

PATIENT DETAILS 		DATE	<TodaysDate>	

Name:	<PtFirstName> <PtMidName>  <PtSurname>	
		
Address:	<PtStreet> <PtCity> <PtState> <PtPostcode>	

Phone:	<PtPhoneH>		Mobile:	<PtPhoneMob>	
					
DOB:	<PtDoB>		Email:	<PtEmail>	

Interpreter?	Yes			No			Language		

GP DETAILS 		

Name:	<DrName>	
		
Address:	<DrStreet> <DrCity> <DrState> 	

Phone:	<DrPhone>		Fax:	<DrFax>	
					
Provider No:	<DrProviderNo>				

CLINICAL INFORMATION 		

LMP __/__/___           EDC __/__/___

	

	OFFICE USE ONLY		

Consultants
Dr Aye (Su) Htun
2690125A	Dr Pui Ru (Kevin) Koh
293106MW	Dr Sacha Strockyj
4170082K	

ANTENATAL EXAMINATION & INVESTIGATIONS	

LMP: ____________   EDB: ____________   GRAVIDA: ____________   PARITY: ____________   

Investigations (tick if attended)

	
Attended	

1	
Blood Group & Antibody screen	
o	

2	
Haemoglobin	
o	

3	
VDRL	
o	

4	
Rubella lgG	
o	

5	
Hep B surface antigen	
o	

6	
Hep C (anti HCV)	
o	

7	
HIV (after discussion)	
o	

8	
Thalassaemia (HbEPG)	
o	

9	
Varicella lgG	
o	

10	
Glucose Challenge Test	
o	

11	
Glucose Tolerance Test	
o	

12	
MSU	
o	

13	
Ultrasound 18-20 wks FAS	
o	

14	
PAP smear	
o	

15	
Low Vaginal swab (as required)	
o	

16	
Other	
o	

Cardiovascular system

BP ___ / ___ at ___ weeks gestation	

Respiratory system

Abdominal examination

Thyroid

Breast Examination

Pre/ early pregnancy weight

Problems in current pregnancy

Other Findings

	

USEFUL PHONE NUMBERS
Canterbury Hospital

Main Switch - 9787 0000
Antenatal Clinic - 9787 0560 - Clinic operating hours 
Monday to Friday - 08:30am to 04:30pm 
(excluding Public Holidays)
Fax - 9787 0431
Birthing Unit - 9787 0555	

		Dear Doctor,
Early Referral for Genetic testing -

If Genetic testing (with Counselling) is required for this woman (eg. age over 35yrs or family history of genetic disease), please arrange before 12 weeks gestation. If this is not possible please ensure timely referral to the antenatal clinic.
Thank you.

Genetic Counselling provided                    Yes  o          No  o
Referred for Genetic Counselling               Yes  o          No  o
Genetic Testing or Screening                    Yes  o          No  o
Nuchal Translucency plus bloods              Yes  o           No  o
CVS                                                          Yes  o           No  o
Amniocentesis                                          Yes  o           No  o
Declined                                                    Yes  o          No  o
Not indicated                                             Yes  o           No  o	

Medical History
Cardiac                                         Yes  o            No  o
Asthma                                         Yes  o            No  o
Hypertension                                Yes  o            No  o
Endocrine                                     Yes  o            No  o
Mental Illness                               Yes  o            No  o
Renal                                            Yes  o            No  o
Epilepsy                                        Yes  o            No  o
GIT                                               Yes  o            No  o
Smoker                                         Yes  o            No  o
STIs                                              Yes  o            No  o
Other                                             Yes  o            No  o

Family History
Diabetes                                    Yes  o            No  o
Hypertension                              Yes  o            No  o
Congenital Abnormalities           Yes  o            No  o
Twins                                         Yes  o            No  o

Other : ___________________________________________ 

_________________________________________________

_________________________________________________

	

Allergies	
<Reactions>	
	
Current Medications	
<SelectedRx>	

Please return this completed form to the woman to bring to her Booking Appointment.