Electroencephalogram (EEG)
 Testing Request Form
Clinical Investigation Unit 
Sunshine Coast University Hospital	Date of referral: Miscellaneous.Date

Re: Patient Demographics.First Name Patient Demographics.Surname
Address: Patient Demographics.Full Address
Date of Birth: Patient Demographics.DOB
Sex: Patient Demographics.Gender
Home phone: Patient Demographics.Phone (Home)
Mobile phone: Patient Demographics.Phone (Mobile)
Medicare Number: Patient Demographics.Medicare Number
DVA Number: Patient Demographics.DVA Number
	
Use this form for requesting EEG TESTING ONLY.
If a clinical consultation is required a separate referral is required.	
Referral to: Referral to	 	
Clinical Question to be answered by EEG:
 Clinical Question 
 Other	
Clinical details (include type of epilepsy, previous brain insult, side of lesion, drugs, alcohol, and previous medical hsitory)
 Details	
Relevant Medical History: 
Relevant medical hx
 Other relevant MHx	
Allergies:
Clinical Details.Allergies	
Date of last episode: Date of last episode	Time of last episode: Time of last episode	
Current Medications:
 Clinical Details.Medication List	
ECT	 ECT	
Intellectual/Physical/Other disabilites which may affect ability to comply with test:
Disabilities
Other Disabilities	
Requested by: Treating Doctor.Name	Provider No.: Treating Doctor.Provider Number	
Contact Phone: Treating Doctor.Phone	Fax: Treating Doctor.Fax	
Office Use Only				
Date of test:
	Time of test:	Neuro OPD appt:	c Cat 1 c Cat 2 c Cat 3	
Form must be completed for test to be performed. Incomplete forms will be returned	

If unable to send electronically, fax to (07) 5202 0555
Specialty referred to: Clinical Investigation Unit