Public Health Nursing (PHN) Referral Form

Middle Initial (optional)

Parent/Guardian (optional)

Parent/Guardian Date of Birth (optional)

Relationship to the Child (optional)

What Language (optional)

Address (optional)

Family is aware of referral? (optional)

Name of Private Insurance Company and ID Number

OHP/Medicaid ID Number

Primary phone (optional)

Other phone (optional)

Maternal issues (optional)

Due date (optional)

Gravida (G) (optional)

Para (P) (optional)

Spontaneous Abortion (SAB) (optional)

Therapeutic Abortion (TAB) (optional)

Gestation Age (optional)

Birth Weight (optional)

Head Circumference (HC) (optional)

Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) (optional)

International Classification of Diseases (ICD-10) codes (optional)

Additional Information (optional)

Would you like feedback about this referral? (optional)

What is the best way to contact you? (optional>

First Name (optional)

Middle Initial (optional)

Last Name (optional)

Facility (optional)

Office Fax (optional)

Primary Care Provider (PCP) (optional)

Address (optional)

Email	homevisitingnurse@clackamas.us
Fax	503-655-8388

Child/Family Contact Information