CQHHS ENDOSCOPY REFERRAL FORM
Central Queensland Hospital & Health Service (CQHHS)  
Secure electronic transfer for CQ Referral Centre
Medical Objects: (XR4700000LZ)
HealthLink EDI: (qldrocop)
Or, fax to the CQ Referral Centre: (1300 017 155)

The above fax number cannot be used for Emergency Department
For CQ condition-specific referral criteria, visit CQ HealthPathways
Referral information                                                                                                                 	
* Re:<PtFirstName> <PtSurname>	* DOB: <PtDoB>  	
Referring GP:	<DrName>	
GP phone number:	<UsrPhone>	
Type of referral request:                          	<Type of referral request>	
Referral date:                                   	<TodaysDate>	
Priority:                                             	<Priority>	
		
Consents	
Date patient consented to referral:                  	<TodaysDate>	
Patient is willing to have surgery if required?	<Patient is willing to have surgery if required>	
Any history of anaesthetic problems?	<Any history of anaesthetic problems?>	
Procedure explained to the patient?	<Procedure explained to the patient>	
Are you the patient's usual GP?	<Are you the patient's usual GP>	
If no, patient's usual GP:	<If no, patient's usual GP name>	
		
Referral recipient                                                                                                                     	
Location / Service / Specialist name (select one only per referral)	
Rockhampton:                                	<Rockhampton - Service - Specialist>	
		
Condition / Specialty specific clinical information - CQ HealthPathways  	
Please print Adult Integrated Pre-Procedure Screening Tool for the patient to fill in and bring to their appointment or fax it with this referral 	
Referral letter	
<Referral Letter - please detail reason for referral>	
		
Gastroscopy	
Bleeding:	<Bleeding>	
Abnormal imaging:	<Abnormal imaging>	
Barretts screening:	<Barrett's screening>	
Date of most recent endoscopy:	<Date of most recent endoscopy>	
Small bowel biopsy - coeliac screening including antibody result:	<Small bowel biopsy - coeliac screen/antibody result>	
Dysphagia:	<Select if dysphagia experienced>	
Nausea / Vomiting / Loss of appetite:	<Select if nausea / vomiting / loss of appetite>	
Weight loss:	<Select if weight loss experienced>	
Pain:	<Pain>	
		
Colonoscopy / Flexible Sigmoidoscopy / National Bowel Cancer Screening Program (NBCSP)	
NBCSP: 	<Select if - National Bowel Cancer Screening>	
NBCSP ID:	<Copy/paste NBCSP ID for patient tracking>	
Details of indications as selected below:	<Details of indications as selected below>	
PR bleeding:	<PR bleeding>	
Altered bowel habit:	<Altered bowel habit>	
Constipation:	<Constipation>	
Diarrhoea:	<Diarrhoea>	
Area of pain:	<Area of pain>	
Surveillance - www.health.qld.gov.au/cq/gp :	<Select surveillance - www.health.qld.gov.au/cq/gp>	
Date of most recent endoscopy:	<Date of most recent endoscopy>	
		
Specialty specific information	
Anti-coagulation / anti-platelet therapy:	<Anticoagulation/antiplatelet therapy>	
	<Details of anticoagulation/antiplatelet therapy>	
Can anti-coagulation therapy be stopped?	<Select if anticoagulation therpy can be stopped>	
Comorbidities:	<Comorbities>	
	<Details of multiple comorbities>	
		
Investigations relevant to this referral	
ALL: Iron studies, urea and electrolytes, haemoglobin level
MALES: >45yrs + ECG, FEMALS: >50yrs + ECG - exception of risk factor: hypertension, smoking, diabetes, gout, family hx or known ischaemic heart disease/angina or cardioactive drugs (e.g. digoxin, amiodarone)	
<Ix>	
		
Imaging and reports	
Have medical images been transferred to the hospital system?	<Medical images transferred to hospital?>	
		
Standard clinical information                                                                                              	
Allergies / adverse reactions	
<Reactions>	
		
Immunisations	
<Imm>	
		
Observations	
<Observations>	
	
Family history	
<FamilyHx>	
		
Social history	
Smoking quitting stage: 	<Smoking Quitting Stage>	
<SocialHx>		
		
Patient information                                                                                                                  	
IHI: 					<PtIHI>	
Name:	<PtFullName>	
Date of birth:          	<PtDoB>	
Gender:                               	<PtSex>	
Indigenous status: 	<PtATSI>	
Occupation:	<PtOccupation>	
Patient's contact details		
Address:	<PtAddress>	
Postal 	(if different from above):	<PtPOAddress>	
Home phone:	<PtPhoneH>	
Mobile:	<PtPhoneMob>	
Does patient consent to SMS contact? 	<Does patient consent to SMS contact?>	
Interpreter required:	<Interpreter required>	
Preferred language:	<Preferred language>	
		
Alternative Contact / Carer Details	
Name:	<NOKName>	
Relationship:	<NOKRelation>	
Phone:		<NOKContact>	
Are there any custody or guardianship issues regarding this patient? 	<Custody or guardianship issues>	
Details of custody/guardianship issues:	<Details of custody or guardianship issues>	
Is the child in and out of home (foster) care?  	<Is the child in and out of home (foster) care>	
Name of child safety service centre:            	<Name of Child Safety Service Centre>	
Has advance care plan?                  	<Has advanced care plan>	
Has enduring power of attorney?    	<Has enduring power of attorney>	

Insurance information                                                                                                               	
Medicare number:                                  	<PtMCNo>	
Medicare expiry:                                    	<PtMCExpiry>	
Pension number:                                   	<PtPensionNo>	
DVA number:                                         	<PtDVANo>	
Health fund:                                           	<PtInsFund>	
		
Referring GP's information                                                                                	
Name: 		 	<DrName>	
Provider number: 		<DrProviderNo>	
Practice details: 			<Practice>	
Address:	<UsrAddress>	
Phone:	<UsrPhone>	
Fax:	<UsrFax>	
Email:	<PracEmail>	
		
I look forward to hearing the outcome of this patient's consultation.	
		
Yours sincerely,		
<DrName>