Prenatal And Postpartum Public Health Referral
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1
2Vancouver Coastal Health
Public Health Program
PRENATAL AND POSTPARTUM PUBLIC HEALTH REFERRAL
See back of Page for Fax Number
Client Aware of Referral?
Yes
No
Note - Public Health will not contact if client unaware of referral
Client Last Name
Client First Name
Address – Number, Street Name
Apt.
Date of Birth (dd/mm/yy)
Age
City/Town
Province
Postal Code
Marital Status
Home Phone #
Work/Alternate Phone #
Language Spoken:
Fluent in English
Yes
No
Personal Health Number (Care Card):
Name of Primary Care Provider
Prenatal
Expected Date of Birth:
G ____ T ____ P ____ A ____ L ____
Postpartum
Date of Baby’s Birth:
Birth Weight
Current Weight
Concerns (Check all that apply):
Mental Health
EPDS Date
Score
If applicable indicate
Age
Financial Stress
Breastfeeding
Limited Cognitive Abilities
Alcohol Use
Inadequate Housing
Substance Use
Nutritional Issues
Tobacco Use
Relationship Issues
Dental
Lack of Support/Isolation
If Other, Specify
Comments:
Referred By: Last Name ______________ First Name _____________ Date _____________
Signature/Title ________________________ Phone ______________ Fax _______________
VCH.VC.0155A | MAY.2013
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