Date: <<Miscellaneous:Date>>

Is this patient suitable for GP Shared Care? <<Is this patient suitable for GP Shared Care?>>

ANC Consultants:	
<<Referring for care at [ST GEORGE HOSPITAL]>> (Dr T Miller, G Davis, Dr A Henry, Dr S Kanitkar, Dr K Kavanagh-Patel, C.Duong)
<<Referring for care at [The Sutherland Hospital]>> (Drs A Zuschmann, D Conrad, A Harris, N Peters, K King, D Krishnan, C Krishnan)

GP Details*
<<Doctor:Name>> 
<<Practice/Location:Name>>
<<Practice/Location:Address>>
<<Practice/Location:Phone>>
GP Shared Care Provider? <<Are you a GP Shared Care Provider?>>

Signed by GP: _____________________________________

*If the collaborating GP is a Registrar, please detail the name and provider number of the supervising GP: <<If Registrar, who is the supervising GP?>>

Patient Details:
Full name: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
Contact number: (h) <<Patient Demographics:Phone (Home)>>      (m) <<Patient Demographics:Phone (Mobile)>>
Email address: <<Patient Demographics:E-mail>>
Home address: <<Patient Demographics:Full Address>>

Patient Declaration:
[<<Does the patient consent >>  ] I agree to my personal and health information being shared between GP and the hospital clinic(s) for the provision of my healthcare.

Signed by patient: ___________________________________________________

_________________________________________________________________________________________________

Current Pregnancy:
Maternal age: <<Patient Demographics:Age>> 
Gravida Para Miscarriage TOP: <<Gravida Para Miscarriage TOP>> 
LMP:  <<LMP>>
EDC determind by...: <<EDC determined by...>>  
Complications so far:  <<Complications so far:>> If Yes <<If Yes, details of complications so far>> 
Screening/imaging results so far: <<Results so far (enter details if applicable)>> 
Smoking/Vaping:  <<Smoking/Vaping>>
Alcohol Consumption: <<Alcohol Consumption:>>      
Other rec. substance use:  <<Other rec. substance use:>>
Allergies: <<Clinical Details:Allergies/Adverse Reactions>>
Multivitamin/CAM/over-the-counter treatments: <<Multivitamin/CAM/over-the-counter treatments: >>
Current prescription medications: <<Clinical Details:Medication List>>

Obstetric/Gynaecological History:
Obstectric/Gynaecology History: <<Obstectric/Gynaecology History: >>
History of birth-related trauma: <<Is there a history of birth-related trauma?>>

Date of last CST on record: <<Clinical Details:Cervical Screening>> 

Family History:     
Any family history of...? <<Family History>> 

Relevent social history: 
Interpreter needed? <<Patient Demographics:Requires Interpreter>>
If Yes, <<Patient Demographics:Language Preferred>>
Relevent Social History: <<Clinical Details:Social History>>
_________________________________________________________________________________________________

Examination at <<Examination at >> weeks’ gestation: <<Week's gestation>>
<<Clinical Details:Measurements (Selected)>>
Physical assessment has included: <<Physical assessment has included: >>
Relevant physical findings: <<Relevant physical findings:>>
__________________________________________________________________________________________________

[ <<Please tick>> ] Please tick this box if there are special circumstances for which a verbal handover between the GP and the hospital clinic early in this pregnancy would be beneficial and important. 
_________________________________________________________________________________________________

Has first trimester screening been arranged? <<Has first trimester screening been arranged? >>
Is this patient on an appropriate prenatal supplement? <<Is this patient on appropriate prenatal supplement>>
Is an early Glucose Tolerance Test indicated? <<Is an early Glucose Tolerance Test indicated?>>
Is low dose aspirin indicated? <<Is low dose aspirin indicated?>>		
Is additional folate supplementation indicated? <<Is additional folate supplementation indicated?>>
Has a DV screen been performed?  <<Has a DV screen been performed? >>
Does this patient have an active My Health Record? <<Does this patient have an active My Health Record>>
__________________________________________________________________________________________________

The following tests have been ordered:
The following routine tests have been ordered (select all that apply).  
FBC: <<Following tests have been ordered: FBC>>
Blood Group: <<Blood Group>>
Red Cell Antibody Screen: <<Red Cell Antibody Screen>>
Rubella IgG: <<Rubella IgG>>
Varicella: <<Varicella IgG>>
Syphilis: <<Syphilis Serology>>
Hepatitis B Surface Antigen: <<Hepatitis B Surface Antigen>>
HIV Serology: <<HIV Serology>>
Hepatitis C Serology: <<Hepatitis C Serology>>
Vitamin D: <<Vitamin D>>
Ferritin: <<Ferritin>>
Mid-Stream Urine MCS: <<Mid-Stream Urine MCS>>
All the above test completed: <<All the above test completed>>

Also these common optional tests have been ordered (select all that apply/ as needed): 
HbEPG (as per hospital guidelines) <<Tests ordered: HbEPG (as per hospital guidelines)>>
Urine chlamydia PCR (if <25 or high risk): <<Urine chlamydia PCR (if <25 or high risk)>>
TSH (if risk factors present): <<TSH (if risk factors present)>>
Vitamin B12 (if vegan or other risk factor): <<Vitamin B12 (if vegan or other risk factor)>>
Cervical SCreening: <<Cervical Screening Test (if due)>>
Other: <<Other:>>

Pathology company: <<Pathology Company>>
Were the antenatal pathology results copied to the Antenatal Clinic? <<Results copied to the Antenatal Clinic?>>
_________________________________________________________________________________________________

 •  INFORMATION FOR PATIENTS  •
Please bring this completed referral form with you when you attend your first antenatal appointment at the hospital. Have you completed the online booking form yet? If not, please follow the relevant link below. You’ll receive an appointment confirmation letter by email. There may be a period of wait between submitting your form online and receiving a reply email.

The Sutherland Hospital	
St George Hospital