Is this patient suitable for GP Shared Care?   [  ] Yes      [  ] No (reason: )
Date: <TodaysDate>

ANC Consultants:	[  ]  STG (Dr T Miller, G Davis, Dr A Henry, Dr S Kanitkar, Dr K Kavanagh-Patel, Dr E Chesterman, Dr E Karantanis, Dr S Thou, Dr J Robertson, Dr K King)
		[  ]  TSH (Dr A Zuschmann, Dr J Breen, Dr D Conrad, Dr A Harris, Dr C Krishnan, Dr K Roper, Dr N Chan, Dr C Krishnan)

GP Details*
Shared Care provider?      [  ] Yes      [  ] No 
<Practice>
<UsrAddress>
<UsrPhone>
<PracEmail>

Referring GP Name: <DrName>
Provider Number: <DrProviderNo>

Signed by GP: 	Patient Details:
Full name: <PtName>
DOB: <PtDoB>
Contact number: (h) <PtPhoneH>      (m) <PtPhoneMob>
Email address: <PtEmail>
Home address: <PtAddress>

[  ] I agree to my personal and health information being shared between my GP and the hospital clinic(s) for the provision of my healthcare.

Signed by patient:
	
* If the collaborating GP is a Registrar, please detail the name and provider number of the supervising GP: 

Current Pregnancy:
LMP:  ___ EDC: <EDC>  [  ] By menstrual calculation  [  ] By early dating scan  [  ] Determined by IVF
Maternal age: __ Gravida: ___  Para:  ___ Complications so far:  [  ] No    [  ] Yes: _
Screening/imaging results so far: __

Current prescription medications:
<SelectedRx>	
Multivitamin/CAM/over-the-counter treatments:	

Allergies: <Reactions>
Smoking:  <SmkStatus>      Alcohol: <AlcHx>      Other rec. substance use:  [  ] No  [  ] Yes

Obstetric/Gynaecological History:
[  ] History of birth-related trauma
[  ] History of Preterm/early term/still birth - details/gestation:______________________________________________
<ObstetricHx>	
Other Personal Medical History:
<SelectedPMH>	

Date of last CST on record: __ / __/ __
Result: 

Relevant Social History:
<SocialHx>
Interpreter needed?  [  ] No  [  ] Yes: 	Family History:                                                      Details if yes â
Genetic conditions	[  ] No  [  ] Yes
Diabetes/GDM		[  ] No  [  ] Yes
Htn/pre-eclampsia	[  ] No  [  ] Yes
Other congenital		[  ] No  [  ] Yes
(e.g. spina bifida, cleft palate, cardiac)
Others not listed: __
None of the above	[  ]	

Examination at __ weeks’ gestation: ___
<Observations>

Physical assessment has included:
[  ] Heart   [  ] Lungs   [  ] Thyroid   [  ] Abdomen   [  ] Breasts	
Relevant physical findings:

[  ] 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. GP’s preferred contact details:

Has first trimester screening been arranged? [  ] No  [  ] Yes, NIPT    [  ] Yes, Combined 1st Trim Screening/NT Plus
Is this patient on an appropriate prenatal supplement?	[  ] No  [  ] Yes
Is an early Glucose Tolerance Test indicated?		[  ] No  [  ] Yes
Is low dose aspirin indicated?				[  ] No  [  ] Yes
Is additional folate supplementation indicated?		[  ] No  [  ] Yes
Has a DV screen been performed?				[  ] No  [  ] Yes
Does this patient have an active MyHealthRecord?		[  ] No  [  ] Yes    [  ] Unsure

The following tests have been ordered:
Routine:
[  ] FBC
[  ] Blood group
[  ] Red cell antibody screen
[  ] Rubella IgG
[  ] Varicella IgG
[  ] Syphilis serology
[  ] Hepatitis B surface antigen
[  ] HIV serology
[  ] Hepatitis C serology
[  ] Vitamin D
[  ] Ferritin
[  ] Mid-stream urine MCS
[  ] All the above test completed	As needed:
[  ] HbEPG (as per hospital guidelines)
[  ] Urine chlamydia PCR (if <25 or high risk)
[  ] TSH (if risk factors present)
[  ] Vitamin B12 (if vegan or other risk factor)
[  ] Cervical Screening Test (if due)
[  ] Other: 

Pathology company:

[  ] Results copied to 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 short waiting period, between submitting your form online and receiving a reply email.

The Sutherland Hospital	
St George Hospital