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.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 	
Transport:	Transport?	
Clinical question to be answered by NCS/EMG
Reason for NCS/EMG
Other details	
Clinical Details:
Other details	
Relevant Medical History:
Relevant medical Hx
 Other medical Hx	
Current Medication:
Anti-Coagulant Anticoagulant         Statins Statins              Antiplatelets Antiplatelets

List other medication names and dosage:
Clinical Details.Medication List	
Allergies:
Clinical Details.Allergies	
Intellectual/Physical/Other disabilities which may affect ability to comply with test:
Disabilities
Other disabilities	
Has a separate SCUH neurology consult been requested? SCUH neurology reque	
Requested by: Treating Doctor.Name	Provider No.: Treating Doctor.Provider Number	
Phone: Treating Doctor.Phone	Fax:Treating 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