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

Send via Medical Objects or Healthlink to:
Dr Vicki Evans
	From Treating Doctor.Name
Practice.Name
Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Email: Treating Doctor.E-mail
Provider Number: Treating Doctor.Provider Number

Miscellaneous.Date

Dear Dr Evans

SECTION 1 Patient details

RE: Patient Demographics.Full Name
DOB: Patient Demographics.DOB

Gender: Patient Demographics.Gender
Address: Patient Demographics.Address
Home Ph: Patient Demographics.Phone (Home)
Mobile Ph: Patient Demographics.Phone (Mobile)
Medicare Number*: Patient Demographics.Medicare Number  (*Medicare ineligible patients will incur a consultation fee)
	Next of Kin/Alternative Contact: Patient Demographics.NOK Name
Next of Kin/Alternative Contact Ph: Patient Demographics.NOK Mobile Phone
Does the patient identify as Aboriginal and/or Torres Strait Islander: Does the pt identify
Interpreter required: Interpreter required
If yes, specify language: If yes, specify lang

SECTION 2 Reason for referral and additional clinical information

What is the  reason for this referral? Reason for referral

Please provide provisional diagnosis (if available): Provisional diagnosi

Please provide history of symptoms: History of symptoms

Please provide date of onset (if known): Date of onset

Please include details of treatment regime so far: Treatment regime

SECTION 3 Mandatory clinical information

Obstetric history:
 Pregnancy.Summary

Clinical examination findings if done: Clinical examination

List any previous procedures: Previous procedures

Current and past medical history:
 Clinical Details.History List

Alcohol:
 Clinical Details.Alcohol

Smoking:
 Clinical Details.Smoking

Clinical Details.Problem List (Current) With Comments

Clinical Details.Problem List (Resolved) With Comments

Allergies:
 Clinical Details.Allergies

Current prescribed medications:
 Clinical Details.Medications - Current Regular

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

Cervical screening:
 Clinical Details.Pap Smear With Comments

STI screening results: STI screening result

Radiology results: Radiology results

Previous surgery reports +/- histology: Previous surgery