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:<<Patient Demographics:Title>> <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>	* DOB: <<Patient Demographics:DOB>>  	
Referring GP:	<<Doctor:Name>>	
GP phone number:	<<Practice:Phone>>	
Type of referral request:                          	<<Type of referral request>>	
Referral date:                                   	<<Miscellaneous:Date>>	
Priority:                                             	<<Priority>>	
		
Consents	
Date patient consented to referral:                  	<<Miscellaneous:Date>>	
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:	<<Diorrhoea>>	
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)	
<<Summary:Investigation Results (Selected)>>	
		
Imaging and reports	
Have medical images been transferred to the hospital impax system?	<<Medical images transferred to IMPAX?>>	
		
Standard clinical information                                                                                              	
Allergies / adverse reactions	
<<Clinical Details:Allergies/Adverse Reactions>>	
		
Immunisations	
<<Clinical Details:Immunisation List>>	
		
Observations	
BMI:	<<Clinical Details:Measurements>>	
Blood Pressure:	<<Clinical Details:Measurements>>	
Blood Sugar Level:	<<Clinical Details:Measurements>>	
Respiratory:	<<Clinical Details:Measurements>>	
		
Family history	
<<Clinical Details:Family History>>	
		
Social history	
Smoking quitting stage: 	<<Clinical Details:Smoking Quitting Stage>>	
<<Clinical Details:Social History>>		
		
Patient information                                                                                                                  	
IHI: 					<<Patient Demographics:IHI>>	
Name:	<<Patient Demographics:Full Name>>	
Date of birth:          	<<Patient Demographics:DOB>>	
Gender:                               	<<Patient Demographics:Gender>>	
Indigenous status: 	<<Patient Demographics:ATSI>>	
Occupation:	<<Patient Demographics:Occupation>>	
Patient's contact details		
Address:	<<Patient Demographics:Full Address>>	
Postal 	(if different from above):	<<Patient Demographics:Full Address Postal>>	
Home phone:	<<Patient Demographics:Phone (Home)>>	
Mobile:	<<Patient Demographics:Phone (Mobile)>>	
Does patient consent to SMS contact? 	<<Does patient consent to SMS contact?>>	
Interpreter required:	<<Patient Demographics:Requires Interpreter>>	
Preferred language:	<<Patient Demographics:Language Preferred>>	
		
Alternative Contact / Carer Details	
Name:	<<Patient Demographics:Next of Kin>>	
Relationship:	<<Patient Demographics:Next of Kin Relationship>>	
Phone:		<<Patient Demographics:Next of Kin Phone>>	
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:                                  	<<Patient Demographics:Medicare Number>>	
Medicare expiry:                                    	<<Patient Demographics:Medicare Expiry Date>>	
Pension number:                                   	<<Patient Demographics:Pension Number>>	
DVA number:                                         	<<Patient Demographics:DVA Number>>	
Health fund:                                           	<<Patient Demographics:Health Insurance>>	
		
Referring GP's information                                                                                	
Name: 		 	<<Doctor:Name>>	
Provider number: 		<<Doctor:Provider Number>>	
Practice details: 			<<Practice:Name>>	
Address:	<<Practice:Address>>	
Phone:	<<Practice:Phone>>	
Fax:	<<Practice:Fax>>	
Email:	<<Doctor:E-mail>>	
		
I look forward to hearing the outcome of this patient's consultation.	
		
Yours sincerely,		
<<Doctor:Name>>