Maternity
Booking-In
Referral	
Hospital use only

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...........................................	
Please complete patient contact details in full--to allow us to contact your patient promptly	

Patient details
Re:	<<Patient Demographics:Full Name>>	
DOB:	<<Patient Demographics:DOB>>	
Address	<<Patient Demographics:Full Address>>	
Home Ph: <<Patient Demographics:Phone (Home)>>	Work Ph: <<Patient Demographics:Phone (Work)>>	
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>		
Next of Kin: <<Patient Demographics:Next of Kin>>	Contact number: <<Patient Demographics:Next of Kin Phone>>	
Medicare number: <<Patient Demographics:Medicare Number>>	Individual Health Identifier: <<Patient Demographics:IHI>>	
Interpreter Required: <<Interpreter required?>>	Language? <<Patient Demographics:Language Spoken>>	
Is the woman of Aboriginal or Torres Strait Islander origin?	<<Patient Demographics:ATSI>>	
Is the child of Aboriginal or Torres Strait Islander origin?	<<Child of Aboriginal or Torres Strait Islander origin?>>	

Referral to:		Referring doctor details:	
<<Addressee:Name>>
Att: <<Addressee:Greeting>>
<<Addressee:Full Address>>
Fax: <<Addressee:Fax>>		<<Doctor:Full Details>>	

Clinical details - current pregnancy
LNMP: <<Clinical Details:LNMP>> (<<LNMP certain/uncertain?>>)		EDB: <<Clinical Details:EDC>>	
Cervical Screening Test:	<<Clinical Details:Cervical Screening>>	

Screening & assessment - prenatal and current pregnancy
Prepair carrier screen (SMA, CF, FXS) optional	Discussed: <<Prepair carrier screen discussed?>>	Ordered: <<Prepair carrier screen ordered?>>	
Extended carrier screen (Beacon) optional	Discussed: <<Extended carrier screen discussed?>>	Ordered: <<Extended carrier screen ordered?>>	
Early HbA1c only if at risk T2DM	Discussed: <<Early HbA1c indicated?>>	Ordered: <<Early HbA1c ordered?>>	
Dating scan (if required)	Discussed: <<Dating scan discussed?>>	Ordered: <<Dating scan ordered?>>	
Nuchal translucency + first trimester serum screen
(11-13 weeks + 6 days) OR	Discussed: <<First trimester screening discussed?>>	Ordered: <<First trimester screening ordered?>>	
Nuchal translucency scan if having NIPT 	Discussed: <<NT screen for woman having NIPT discussed?>>	Ordered: <<NT scan for woman having NIPT ordered?>>	
Chorionic Villus Sampling (CVS)	Discussed: <<CVS discussed?>>	Ordered: <<CVS ordered?>>	
Amniocentesis	Discussed: <<Amniocentesis discussed?>>	Ordered: <<Amniocentesis ordered?>>	
Non-invasive prenatal testing (NIPT)	Discussed: <<NIPT discussed?>>	Ordered: <<NIPT ordered?>>	
Morphology diagnostic ultrasound (18-20 weeks)	Discussed: <<Morphology scan discussed?>>	Ordered: <<Morphology scan ordered?>>	
Pertussis booster (from 20 weeks)	Planned: <<Pertussis booster planned after 20 weeks?>>	Given: <<Pertussis booster given (from 20 weeks)?>>	
Antenatal screening blood tests ordered via:	<<Antenatal screening laboratory?>>	<<Which "other" pathology laboratory?>>	

Significant obstetric history:
Gravidity: <<Clinical Details:Gravida>>	Parity: <<Clinical Details:Parity>>	Miscarriages: <<Miscarriages?>>	Ectopics: <<Ectopics?>>	TOP: <<TOPs?>>	

Past Obstetric History:
<<Clinical Details:Past Obstetric History>>

Measurements
<<Clinical Details:Measurements>>

Antenatal Visits
<<Clinical Details:Antenatal Visits>>

Significant medical/surgical history: 
<<Clinical Details:History List>>

Medication List:
<<Clinical Details:Medication List>>

Allergies:
<<Clinical Details:Allergies>>

Smoking & Alcohol
Cigarettes: <<Clinical Details:Smoking>>		Alcohol: <<Clinical Details:Alcohol>>	

Warnings and alerts:
<<Clinical Details:Warnings>>

Other comments: (eg social concerns, BMI)

 <<Other comments: (eg social concerns, BMI)>>

Private patients in Public Hospitals - National Health Reform Agreement

Named referrals are optional in Qld for patients choosing to be "treated as a private patient" in a public hospital under G19(b); and under G17(b) referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services 

http://www.federalfinancialrelations.gov.au/content/npa/health/_archive/national-agreement.pdf

Referring doctor's signature:............................................................Date: <<Miscellaneous:Date (short)>>

Investigations:

<<Summary:Investigation Results (Selected)>>