Enhancing Paediatrics in Primary Care (EPiPC) Clinical Query Proforma  
FAX to (02) 69339268 or EMAIL to <MLHD-CCH@health.nsw.gov.au>
If no response received within 2 weeks, please contact <MLHD-CCH@health.nsw.gov.au> directly to ensure Clinical Query has been received. 

Patient details*
Patient name		
DOB		
Medicare number		
Primary carer name:		Primary carer DOB:		
Address		
Contact mobile		Email		

Demographic details:
 Aboriginal and/or Torres Strait Islander 		 Refugee or Asylum Seeker

 Culturally And Linguistically Diverse (CALD)		 Interpreter required (language___________)

 Out Of Home Care (OOHC)				 DCJ/ support service involved

Primary issue/concern*
 Early childhood developmental concern	
 Early childhood behavioural concern
 Both early childhood developmental and behavioural concerns	

If developmental concern, please indicate which domain(s) is/are affected	
 Speech & language 	 Fine motor		 Gross motor	 Personal/social
 Problem solving/cognitive 			 Global 

Preferred format
 Email support								

Specific clinical question(s) for Community Paediatrician to address*

Short summary of child’s medical history relevant to the clinical question(s) above* 

	

Services currently involved:
 Speech pathology				 Occupational Therapy
 Psychology/ counselling/ school counsellor	 Physiotherapy
 Dietitian						 Other

Further details of services involved

	

Referrer details*
Name	
	
Practice location	
	
Preferred contact details for correspondence 
(e.g. email/fax)		
Signature	
	Date		
If GP registrar, name and contact details of GP supervisor		GP supervisor co-sign		
If no response received within 2 weeks, please contact <MLHD-CCH@health.nsw.gov.au> directly to ensure Clinical Query has been received.