Sunshine Coast Hospital & Health Service (SCHHS) Central Intake 
GASTROENTEROLOGY OPEN ACCESS ENDOSCOPY REFERRAL FORM

Secure electronic transfer to: (NQ45600007J)
Specialty referred to: Endoscopy
(Alternatively this referral can be faxed to the Central Booking Office on Fax: 07 5202 0555)

Open Access Endoscopy Request

Specialist - <<Specialist referred to? >>	
(Affix patient label here)	
Referring Doctor details	Patient Details	
Referring doctor: <<Doctor:Name>>
Date of referral: <<Miscellaneous:Date>>
Practice address: <<Practice:Address>>
Contact details – Phone: <<Practice:Phone>>
                               Fax: <<Practice:Fax>>
	Re:  <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Address: <<Patient Demographics:Full Address>>
Phone – Home: <<Patient Demographics:Phone (Home)>>
                Mobile:  <<Patient Demographics:Phone (Mobile)>>
DOB: <<Patient Demographics:DOB>>
Sex:  <<Patient Demographics:Gender>>	
UPPER GI ENDOSCOPY      <<Upper GI endoscopy request>>                                                                    	

Indications (tick all that apply) 
Suspected upper GI cancer on imaging <<Suspected upper GI cancer on imaging >>
Suspected upper GI cancer on clinical examination  <<Suspected upper GI cancer on clinical examination>>
Dysphagia  <<Dysphagia>>
Dyspepsia/heartburn/reflux  <<Dyspepsia/heartburn/reflux>>
Abdominal pain <<Abdominal pain >>
Anaemia <<Anaemia >>
Iron deficiency <<Iron deficiency>>
Persistent vomiting <<Persistent vomiting>>
Gastrointestinal bleeding <<Gastrointestinal bleeding>>
Weight loss (>5% body weight over 6 months) <<Weight loss (>5% body weight over 6 months)>>
Faecal calprotectin positive <<Weight loss (>5% body weight over 6 months)>> 
Oesophageal varices surveillance <<Oesophageal varices surveillance>>
Barrett's surveillance <<Barrett's surveillance>> 

Other indication: 
<<Other upper GI indication (please specify)>>

Date of last upper GI endoscopy: <<Date of last upper GI endoscopy, if known>>

COLONOSCOPY        <<Colonoscopy request>>                        (Tick Indications)	
Indications (tick all that apply): 
Mass palpable on abdominal examination <<Mass palpable on abdominal examination >>
Mass palpable on rectal examination <<Mass palpable on rectal examination>>
Suspected lower GI cancer on imaging <<Suspected lower GI cancer on imaging>>
iFOBT positive - asymptomatic <<iFOBT positive - asymptomatic>>
Abdominal pain <<Abdominal pain >>
Anaemia  <<Anaemia>>
Iron deficiency <<Iron deficiency>> 
Persistent altered bowel habit <<Persistent altered bowel habit >>
Rectal bleeding - bright red blood <<Rectal bleeding - bright red blood>>
Dark blood coating or mixed with stool <<Dark blood coating or mixed with stool >>
Nocturnal diahorrea <<Nocturnal diahorrea >>
Weight loss (>5% body weight over 6 months) <<Weight loss (>5% body weight over 6 months)>>
Positive faecal calprotectin <<Positive faecal calprotectin>>
Colorectal polyp surveillance (attached previous reports) <<Colorectal polyp surveillance (pls attach reports)>>
Family history colorectal cancer <<Family history of colorectal cancer (give details) >>
Post-operative following CRC resection <<Post-operative colorectal cancer resection>>
Inflammatory bowel disease surveillance <<Inflammatory bowel disease surveillance>>

Other indication:
<<Other colonoscopy indication>>

Date of last colonoscopy: <<Date of last colonoscopy, if known>>
	
REQUIRED INFORMATION	
Personal or family history of Barrett’s or GI cancer (give details):  <<Personal/family hx of Barrett's or GI Ca (give details)>>
Essential investigations FBC, ELFT, Iron Studies (please attach)  
<<Essential investigations attached>>

Details of any anticoagulation (tick all that apply): 
<<Details of anticoagulation >>

Diabetes history:
<<Diabetes history>>

Any other relevant past medical history (GI surgery, cardiac or lung disease):
<<Other medical hx (GI surgery, cardiac/lung disease)>>	

This referral is for an Open Access Endoscopy only.
A Gastroenterology Outpatient review will only be organised if clinically necessary	
Please refer to Health Pathways for referral advice and encourage the patient to complete the patient health questionnaire. For further information contact endoscopy unit Ph. 5202 2222	
SCHHS-funded care at a private facility
If deemed medically appropriate, treatment and care for patients on a Sunshine Coast Hospital and Health Service theatre waiting list may be transferred to a private hospital and will require release, use and disclosure of personal and health information by Sunshine Coast Hospital and Health Service and the facility to which care is transferred (in accordance with the Privacy Act). 
If the patient does NOT consent to care at another facility please tick box
	
Departmental use only	
Triage Category	
c 4 	
c 5	
Timeframe:	

	
c GI	
c Hep	
Category:	

	
c SCUH	
c NGH	
c GH	
c SCUPH	

c  None	
c Nurse phone clinic	

	

If unable to send electronically, fax to (07) 5202 0555
Investigations <<Summary:Investigation Results (Selected)>>