The Children’s Hospital at The Cleveland Clinic - USF Health
FETAL CARE CENTER OF TAMPA BAY
REFERRAL QUESTIONAIRE FOR ALL REFERRALS
Please fax this form, sono report and prenatals including demographics to: (813) 259-0839
e-mail: aodibo@health.usf.edu or pbornick@ · toll-free: (877) fetal77 · phone: (813) 259-8513
Today’s Date ____/____/___ Referring Diagnosis _____________________________________________________
Patient’s Last Name ______________________________ First Name _____________________________ Age ______
Patient’s Home Phone _______________________Cell _________________________ Date of Birth ____/____/___
Gravida________Para_______ Ab________Living Chidren_____ GA __________LMP ____________EDC___________
Allergies ________________________Ht ______Wt________ Insurance Company _____________________________
Referring Physician _________________________________________________ Phone ________________________
Address ____________________________________________________________ Fax: _________________________
City _____________________________________________ State ______________ Zip _______________________
1. Have the parent(s) been told about the baby’s diagnosis? ___________________________________________
2. Any needs/concerns expressed by the parent(s). __________________________________________________
3. If a serum screen or non-invasive prenatal testing has been performed is there an increased risk for:
Down’s Syndrome? ___Yes____No Neural tube defect? ____Yes ___No Others? ____Yes ___No
Details: ____________________________________________________________________________________
4. Has the patient undergone any diagnostic genetic procedures? ___ Amnio ___ CVS ___ None
5. If a diagnostic genetic procedure has been performed, please provide: Date_________ Results_____________
6. Does this patient have a history of any cervical shortening? ____ Yes _____ No; if Yes, Cervical Length ______
7. Has this patient experienced any symptoms of preterm labor? _____ Yes _____ No
8. Please list any medications/interventions for preterm labor?
Cervical Cerclage? ____Yes ___No Steroids? ________ Progesterone Therapy? ______________________
List any Tocolytic Agents: ______________________________________________________________________
9. Please list any pertinent maternal medical conditions (i.e. diabetes, hypertension, lupus, CHD, etc.)
____________________________________________________________________________________________
____________________________________________________________________________________________
10. Please list both prescription and over the counter medications (baby aspirin) that the patient is taking?
____________________________________________________________________________________________
11. Anticipated site of delivery? _______________________ May we contact the patient at this time? ____Yes ___No
Name and phone number of person completing this form: __________________________________________________
|Office use only: |
|DATE RECEIVED ________________________________________________ DIAGNOSIS _______________________________________ |
|RECOMMEDATION ________________________________________________ FOLLOW UP ______________________________________ |
Thank you for this referral, we will get back with you as soon as possible.
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