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 <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

<<Miscellaneous:Date (long)>>

Dear Dr Evans

SECTION 1 Patient details

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>

Gender: <<Patient Demographics:Sex>>
Address: <<Patient Demographics:Full Address>>
Home Ph: <<Patient Demographics:Phone (Home)>>
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>
Medicare Number:<<Patient Demographics:Medicare Number>> <<Patient Demographics:Medicare Expiry Date>>
	Next of Kin/Alternative Contact: <<Patient Demographics:Next of Kin>>
Next of Kin/Alternative Contact Ph: <<Patient Demographics:Next of Kin Phone>>
Does patient identify as Aboriginal and/or Torres Strait 
Islander: <<Patient Demographics:ATSI>>
Interpreter required: <<Interpreter required>>
If yes, specify language: <<If yes, specify language>>

SECTION 2 Referral details

What is the main 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: <<Clinical Details:Past Obstetric History>>

Clinical examination findings if done: <<Clinical examination findings if done>>

List any previous procedures: <<Provide details of previous procedures>>

Current and past medical history: <<Clinical Details:History List>>

Alcohol: <<Clinical Details:Alcohol>>

Smoking: <<Clinical Details:Smoking>>

Allergies: <<Clinical Details:Allergies/Adverse Reactions>>

Current prescribed medications: <<Clinical Details:Medication List>>

SECTION 4 Investigations

Pleae indicate whether the following investigatons 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: <<FBC, EUC, LFTs, CRP, Iron studies, Hormone prof>>

Cervical screening: <<Clinical Details:Cervical Screening>>

STI screening results: <<STI screening results>>

HVS MCS results: <<HVS MCS results>>

Radiology results: <<Radiology results>>

Previous surgery reports +/- histology:  <<Previous surgery reports +/- histology>>