REFERRAL & ANTENATAL BOOKING FORM
St George / Sutherland Hospitals and Health Services
South Eastern Sydney Local Health District
Information about your health and wellbeing will be collected and be available to both the hospital and your GP unless otherwise requested.
	Patient to complete this section		

Surname: <PtSurname>	Given Names:  <PtFirstName>	
Previous/Maiden Name: 	Occupation: <PtOccupation>	
Marital status:    <PtMaritalSt>	
Date of Birth:  <PtDoB>	Country of Birth:  	Religion:	
Medicare card no:  <PtMCNo>	 Exp date:  	
Language spoken at home:	Interpreter needed?      Yes o No o	
Will the baby be Aboriginal?      Yes o No o	Will the baby be Torres Strait Islander:        Yes o No o	
Pre-pregnancy weight: <Measurements>	Height: <Measurements>	
Home Address	Next of Kin	
Street:  <PtAddress>	Name:  	
	Relationship:  	
Suburb:  <PtCity>	Street:  	
State:  <PtState> P/Code: <PtPostcode>	Suburb: 	
Phone no (H):  <PtPhoneH>	 State:  	
P/Code:  	

(w)  <PtPhoneWk> (Mob)  <PtPhoneMob>	Phone no: 	
Medicare Eligibility:  Overseas (no medicare) o    Reciprocal o Medicare o	
 Medicare card no:  <PtMCNo>	 Exp date:  	
Health Fund:   Yes o No o	Fund name:  	Policy no: 	
Insured for pregnancy related services: Yes o No o Not sure o	
Are you aware of the obstetric private billing arrangement:   Yes o No o	

Have you previously attended St George Hospital before?	 Yes o No o	
Have you previously attended Sutherland Hospital before?	    Yes o No o	
If yes, under what surname?		

 Have you previously received pregnancy care at St George ( o ) or Sutherland (    o ) Hospitals? 
If so, which clinic did you attend?	

	

Would you like the same care for this pregnancy?	    Yes o No o	
(The options below are low risk pregnancy)	
Are you interested in the St George Home Birth Centre for your pregnancy care?	 Yes o No o	
 Are you interested in the St George Home Birth program with a midwife for pregnancy care?	    Yes o No o	

 (USEFUL PHONE NUMBERS 

Centralised Antenatal Appointment 
Booking Inquiries 

(02) 9113 2162 

St George Hospital 		
Main Switchboard		 	   9113 1111

Sutherland Hospital		
Main Switchboard			   9540 7111

Interpreter Service		   131 450	

Please bring this completed form with you when you attend your first antenatal appointment. 

The location of your appointment will 
be advised on your appointment 
confirmation letter. 

REFERRAL & ANTENATAL BOOKING FORM
St George / Sutherland Hospitals and Health Services
South Eastern Sydney Local Health District

GP Name	
<DrName>	

Practice name	
<Practice>	

Practice Address	
<UsrAddress>	

Fax:	
<UsrFax>	

Ph:	
<UsrPhone>	

Provider no: 	
<DrProviderNo>	

	THIS WOMAN IS TO RETURN 
TO ME FOR SHARED CARE? 
   Yes o No o
GP Signature	

Date:	
<TodaysDate>	

		
When offering Nuchael Translucency Plus testing- please counsel and organise before 12 weeks gestation or ensure early referral to the Antenatal Clinic. 	
I wish to share my pregnancy care with my GP and the hospital clinic(s).  I understand that this involves sharing personal and health information between these two services.	
Name:	<PtName>	Signature:		Date:	<TodaysDate>	
	
Antenatal Clinic 
Consultants 	    SGH    Drs T. Miller, S. Thou, 
 o G. Davis, A.Henry & S. Kanitkar	   TSH     Drs A. Zuschmann and
 o J. Breen	
	
NAME:	
<PtFirstName>	

L.M.P	
<LMP>	
AGE	
<PtAge>	

E.D.C	
<EDC>	

Gravida	
	
Para	
<Parity>	

PRESENT PREGNANCY   
  PV Bleeding:	
           Yes o No o 	

Current Medications:	

	

Drugs of addiction:	

Cigarettes-no/daily:	
<SmkStatus>	

Alcohol–gm/week:	
<AlcHx>	

Allergies:	
<Reactions>	

PREVIOUS OBSTETRIC HISTORY:

	

FAMILY HISTORY	
 Yes o No o 	

Cardiac	
      o      o 	

Diabetes	
      o      o 	

Hypertension	
      o      o 	

Twins	
      o      o 	

Hepatitis B	
      o      o 	

 Other congenital abnormalities	
 o      o 	

Specify:	

v Interpreter needed?	
 Yes o No o 	

v     Language required:	

EXAMINATION
BP	
	
at	
	
weeks gestation	

Heart	

BMI	

Lungs	
	
Thyroid	

Abdomen	

Breast examination	

Other findings	

	MEDICAL HISTORY 	
Yes	
No	

Cardiac	
o 	
o	

Asthma	
o 	
o	

Hypertension	
o 	
o	

Diabetes	
o 	
o	

Hepatitis	
o 	
o	

Infertility	
o 	
o	

Tuberculosis	
o	
o	

Sexually Transmitted Infections	
o	
o	

Transfusions	
o	
o	

Mental Illness	
o	
o	

Depression/Anxiety	
o	
o	

Renal	
o	
o	

Epilepsy	
o	
o	

Other past History:	

	

SOCIAL HISTORY	

	

Please ensure the following results 
are available: 	

(and a copy to be sent to the Antenatal Clinic/Birth Centre) 	

Blood group & antibody screen 	
o 	

Full blood count	
o 	

Haemoglobin EPC (as per hospital guidelines) 	
o 	

Rubella IgG	
o 	

Varicella IgG	
o 	

Syphilis (ELISA)	
o 	

Hepatitis B (surface antigen)	
o 	

HIV/Hep C (offered with counselling)	
o 	

Vitamin D	
o 	

MSU for M/C/S	
o 	

    (plus Chlamydia PCR if <25 or high risk)	

Pap Smear	
o 	

Pathology Laboratory 	

18 weeks ultrasound booked 	
Yes o	
No o	

Genetic counselling arranged 	
Yes o	
No o	

NT Plus /CVS / Amnio arranged	
Yes o	
Declined o 	

(Please circle)
Not discussed o Please specify	

	

Updated May 2015