Electroencephalogram (EEG)
 Testing Request Form
Clinical Investigation Unit 
Sunshine Coast University Hospital	Date of referral: <TodaysDate>

Re: <PtFirstName> <PtSurname>
Address: <PtAddress>
DOB: <PtDoB>
Sex: <PtSex>
Home phone: <PtPhoneH>
Mobile phone: <PtPhoneMob>
Medicare Number: <PtMCNo>
DVA Number: <PtDVANo>
	
Use this form for requesting EEG TESTING ONLY.
If a clinical consultation is required a separate referral is required.	
Referral to:	 <Specialist referral to?>	
Clinical Question to be answered by EEG:
<Clinical question to be answered by EEG>
<Other clinical question to be answered by EEG>	
Clinical details (include type of epilepsy, previous brain insult, side of lesion, drugs, alcohol, and previous medical hsitory)
<Clinical details (include type of epilepsy, previous brain insult, side of lesion, drugs, alcohol, and previous medical hsitory)> 	
Relevant Medical History: 
<Relevant Medical History>
<Other relevant medical history>	
Allergies:
<Reactions>	
Date of last episode: <Date of last episode>	Time of last episode: <Time of last episode>	
Current Medications:
<SelectedRx>	
ECT	<ECT>	
Intellectual/Physical/Other disabilites which may affect ability to comply with test:
<Intellectual/Physical/Other disabilites which may affect ability to comply with test>
<Other disabilites which may affect ability to comply with test>	
Requested by: <DrName>	Provider No.: <DrProviderNo>	
Contact Phone: <DrPhone>	Fax: <DrFax>	
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	
Secure electronic transfer to: (NQ45600007J)
If unable to send electronically, fax to (07) 5202 0555
Specialty referred to: Clinical Investigation Unit