Electroencephalogram (EEG)
 Testing Request Form
Clinical Investigation Unit 
Sunshine Coast University Hospital	Date of referral: <<Miscellaneous:Date>>

RE: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Full Address>>
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 EEG TESTING ONLY.
If a clinical consultation is required a separate referral is required.	
Referral to:	 <<Specialist referral to?>>	
Clinical Question to be answered by EEG: 
<<Clinical question to be answered by EEG>>
<<Other clinical question to be answered by EEG>>	
Clinical details (include type of epilepsy, previous brain insult, side of lesion, drugs, alcohol, and previous medical history)
<<Details(epilepsy type, brain insult/lesion, Hx, AOD) >>	
Relevant Medical History:  <<Relevant Medical History>>
<<Other relevant medical history>>	
Allergies:
 <<Clinical Details:Allergies/Adverse Reactions>>	
Date of last episode: <<Date of last episode>>	Time of last episode: <<Time of last episode>>	
Current Medications:
<<Clinical Details:Medication List>>	
ECT	<<ECT>>	
Intellectual/Physical/Other disabilities which may affect ability to comply with test:
<<Intellectual/Physical/disabilities affecting test >>
 <<Other disabilities which may affect ability to comply >>	
Requested by: <<Doctor:Name>>	Provider No.: <<Doctor:Provider Number>>	
Contact Phone: <<Doctor:Phone>>	Fax: <<Doctor:Fax>>	
Office Use Only				
Date of test:
	Time of test:	Neuro OPD appt:	c Cat 1 c Cat 2 c Cat 3	
Form must be completed for test to be performed. Incomplete forms will be returned	

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