Nerve Conduction Studies
Testing Request Form
Clinical Investigations Unit
Sunshine Coast University Hospital

	Date of referral:<<Miscellaneous:Date>>

RE:<<Patient Demographics:First Name>> <<Patient Demographics:Surname>> 
Address:<<Patient Demographics:Full Address>>
DOB: <<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 Nerve Conduction Studies TESTING ONLY.
If a clinical consultation is required a separate referral is required.	
Referral to:	 <<Specialist referred to?>>	
Transport:	<<Transport?>>	
Clinical question to be answered by NCS/EMG
 <<Clinical question to be answered by NCS/EMG>>
 <<Other clinical question answered by NCS/EMG>>	
Clinical Details:
<<Other clinical details>>	
Relevant Medical History:
 <<Relevant medical history>>
 <<Other relevant medical history (please specify)>>	
Current Medication: 
  <<Current Medication>>                     
List other medication names and dosage:
 <<Clinical Details:Medication List>>	
Allergies:
 <<Clinical Details:Allergies/Adverse Reactions>>	
Intellectual/Physical/Other disabilities which may affect ability to comply with test: <<Disabilities which may affect test compliance>>
<<Other Disabilities which may affect test compliance>>	
Has a separate SCUH neurology consult been requested?
 <<Separate SCUH neurology consult been requested>>	
Requested by: <<Doctor:Name>>	Provider No.: <<Doctor:Provider Number>>	
Phone:<<Doctor:Phone>>	Fax: <<Doctor:Fax>>	
OFFICE USE ONLY		
Date of test: 	Time of Test:	
c Cat 1	c Cat 2	c Cat 3	c 30 min	c 45 min	c 60 min	

Secure electronic transfer to: (NQ45600007J)
If unable to send electronically, fax to (07) 5202 0555
Specialty referred to: Clinical Investigation Unit