REQUEST FOR CONSULTATION
Endometriosis and Pelvic Pain Clinic
Medical Super Clinic Benowa

SEND TO Dr Vicki Evans (General Practitioner/Clinical Director)
Endometriosis and Pelvic Pain Clinic
Medical Super Clinic Benowa
192 Ashmore Road
Benowa

Secure Transmission Service via Medical Objects, Healthlink to:
Dr Vicki Evans	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

Dear Dr Evans

SECTION 1 Patient details

RE: <PtFullName>
DOB: <PtDoB>

Gender: <PtSex>
Address: <PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>
Medicare Number*: <PtMCNo> (*Medicare ineligible patients will incur a consultation fee)	Next of Kin/Alternative Contact: <NOKName>
Next of Kin/Alternative Contact Ph: <NOKContact>
Does patient identify as Aboriginal and/or Torres Strait Islander: <Does pt identify as Aboriginal/Torres Strait Islander>
Interpreter required: <Interpreter required>
If yes, specify language: <If yes, specify language>	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: <Specify main reason for referral>
Please provide provisional diagnosis (if available): <Provisional diagnosis if available>
Please provide history of symptoms: <History of symptoms>
Please provide date of onset (if known): <Date of onset if known>
Please include details of treatment regime so far: <Treatment regime so far if known>

SECTION 3 Mandatory clinical information

Obstetric history:  <ObstetricHx>
Clinical examination findings if done: <Clinical examination findings if done>
List any previous procedures: <Provide details of previous procedures>
Current and past medical history: <PMHAll>
Alcohol: <AlcHx>
Smoking: <SmkStatus> <SmkHx>
Allergies: <Reactions>
Current prescribed medications: <CurrentRx>

SECTION 4 Investigations

Please indicate whether the following investigations have been undertaken and attach the results. In addition, please also attach any investigation results you consider to be relevant.

Please include the following results if available:

Bloods: FBC, EUC, LFTs, CRP, Iron studies, Hormone profile: <Bloods: FBC, EUC, LFTs, CRP, Iron studies, Hormone profile>
Cervical screening: <PapSmears>
STI screening results: <STI screening results>
HVS MCS results: <HVS MCS results>
Radiology results: <Radiology results>
Previous surgery reports +/- histology: <Previous surgery reports +/- histology>
Observations: 
<Ix>