For WashCo Use Only
RN:
Public Health Nurse Referral for Washington County Field Team
Progr:
WASHINGTON COUNTY HEALTH & HUMAN SERVICES, Field Team Department
155 North First Ave MS-4 Hillsboro OR 97124-3072
503-846-5717 (Susan Pinnock, RN); 503-846-4872 (Nena Newsom); Fax 503-846-5712
Date:
Client/Mom: ____________________________, __________________________
Spouse
DOB: ___-___-___
Partner: ________________________, _______________________
DOB: ___-___-___
Baby/Child: ______________________________, _______________________
♀ ♂
DOB: ___-___-___
Address: ____________________________________________________________________ 97 __ __ __
Street Address or Route No.
Phone: _____-_____-_______ H C
Engl-Speaking
Aware of referral?
Apt. #
City
Add’l Phones: _____-_____-________ H C
Zip
_____-_____-_______
Other Language: _____________________ Will we need an interpreter?
Y
N
Y
N
Referred by: _________________ of ________________ Phone: ___-____-_______
Health Care Provider: ______________________________________
Health Insurance: Private Ins. Medicaid
Cawem
Phone: ____-_____-______
mom#_______________
baby#_______________
Reason(s) for Referral
Infant/Child
Gestational Age at Birth _______ Wt (g) _______ Lg _____ HC _____ Apgars______
Drug-exposed infant
Congenital/chronic problem
Developmental delay
Feeding problem (breast/bottle)
High wt Low wt Failure to thrive
Twin/triplet
Prenatal--Due Date: _____-_____-_____
Prenatal care > 27 weeks
History of preterm birth
History of fetal demise
Nutrition: overweight
History of gestational diabetes
Pre-eclampsia/toxemia
Developmental delays
Grandmultiparous
C-Sec
Vag
Forceps
Prematurity
Other
(list in comments)
G___ P____ AB____ L____
PN with twins/triplets/more
History of low birth weight
History of SIDS
Inadequate gain
First-time mom
High-risk psychosocial concerns:
• Domestic violence
• Mental health diagnosis including Post Partum
Depression
• Substance abuse: Drugs Etoh Smoking
• History of poor parenting/attachment
• History of Child Welfare involvement
• History of poor attendance at appointments
Additional Information: _____________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________ ⋆Feedback requested? Y N
Date: ____-____-____
Revised: 09/2015
Signature of Writer: ___________________________________