REQUEST FOR PREGNANCY LOSS ON USS (EPAS) APPOINTMENT 
FAX:  4215 2086 
GP Referral
		Referral Date: Miscellaneous.Date

Feedback Requested:  Yes	

Referral to:
Barwon Health Early Pregnancy Assessment Service (EPAS)

Phone: 03 4215 2060
Fax: 03 4215 2086

EPAS Midwife: 0481 483 007

		Referring General Practitioner:
Treating Doctor.Name
Address: Practice.AddressHPI-O:
Ph: Practice.Phone
Fax: Practice.Fax 
Provider No.: Treating Doctor.Provider Number
HPI-I:	

Consumer details:
Name: Patient Demographics.Full Name
Date of Birth:.Patient Demographics.DOB
Age:.Patient Demographics.Age
Sex: Patient Demographics.Gender
Title: Patient Demographics.Title
IHI: Patient Demographics.IHI Number
Ethnicity:  Patient Demographics.ATSI Status
		Contact Address:
Patient Demographics.Full Name
Patient Demographics.Full Address
Tel (H): Patient Demographics.Phone (Home)
Tel (M): Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Alternative Contact: 

Interpreter required: Interpreter required			
Preferred language is: Language required		Medicare Number: Patient Demographics.Medicare Number	
Pension Card Number: Patient Demographics.Pension Number		Private Ins:Patient Demographics.Health Fund Member Number	

Date patient consented to referral:  Miscellaneous.Date	
Consent to share information:  Share information	
Consent to MBS bulk billing clinic if available:  MBS Clinic  	

CLINICAL INFORMATION:
Patient details: Patient Demographics.Full Name  Patient Demographics.DOB     
WestVic HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways

Reason for patient referral:  MUST BE CLINICALLY STABLE
Referral
Relevant Medical Hx: 
Relevant Medical Hx

LNMP: Date LNMP  Gravida:Gravida    Para: Para   Blood Group: Blood group BMI: BMI
Estimated gestation: Estimated gestation  bHCG: bHCG Last cervical Screen test: Last cervical screen	
USS Completed: USS Undertaken
	
Warnings: Clinical Details.Warnings	
Allergies: Clinical Details.Allergies	

Current Medication:
Clinical Details.Medications Current Regular	
Social History:
Clinical Details.Social History
Clinical Details.Smoking  
If yes to smoking, has cessation program been discussed?:  Smoking cessation
Clinical Details.Alcohol (Summary)	
Past Medical History: 
Clinical Details.Problem List (Resolved) With Comments	
Current Medical History:
Clinical Details.Problem List (Current) With Comments	

Investigation Results: (Please cc EPAS for all investigations ordered)
Pathology provided by: Pathology provider

bHCG: bHCG ordered? Blood group: Blood group ordered? FBE: FBE ordered?  
Antibodies: Antibodies ordered? Urine MC&S: Urine MC&S ordered?  Syphilis: Syphilis ordered?
Urine PCR Gonorrhoea: Urine PCR Gonnorhoea  Urine PCR Chlamydia: Urine PCR Chlamydia?

Ultrasound:
Date USS ordered? Date USS ordered?   USS Provider: USS provider?

PLEASE ATTACH ALL PATHOLOGY RESULTS AND ULTRASOUND SCANS TO REFERRAL