Wide Bay Hospital and Health Service
GASTROENTEROLOGY
SERVICES REFERRAL

Referral to:
<Referral to> - <If other,  please state>	RE: <PtFirstName> <PtSurname>
Family name: <PtSurname>
Given names: <PtFirstName> <PtMidName>
Address: <PtAddress>
Contact phone - home: <PtPhoneH> 
work: <PtPhoneWk> mobile: <PtPhoneMob>
Date of birth: <PtDoB>          Sex: <PtSex>	

Date of referral: <TodaysDate>            Provider No: <DrProviderNo>
Referring GP: <DrName>                     GP practice: <Practice>
Email: <DrEmail>
.................................................................................
PATIENT DETAILS
Medicare number: <PtMCNo> Number on card: <PtMCLine> Expiry: <PtMCExpiry>
Private health: <Private health?> Fund-name: <PtInsFund> Fund number: <PtInsNo>
Interpreter required? <Interpreter required?> Language: <Language?>
.................................................................................
REFERRAL
Referred for: <Referred for>
Brief clinical summary:
<Brief clinical summary>
.................................................................................
PATIENT CLINICAL DETAILS
Diabetes: <Diabetes Type I> Type I   <Diabetes Type II> Type II   <Requires insulin> Requires Insulin
<Obesity> Obesity   <Alcohol excess> Alcohol excess   <Current smoker> Current smoker   <Recreational drug use> Recreational drug use
Anticoagulation therapy: <Anticoagulation therapy>
Previous malignancy: <Previous malignancy>
Current malignancy: <Current malignancy>
Family history of GI malignancy: <Family history of GI malignancy>

GP Notes: 
• Please attach a summary letter if the case is complex or you think this may assist us.
• Referrals will be returned to the referring doctor if they are incomplete or illegible.
• Patients should be referred with their results of appropriate investigations only after they have been reviewed by the referring doctor.
• Priority will be given to those patients with clear evidence of alarm symptoms and/or abnormal test results (imaging and/or blood, fecal tests) that correlate / support the reason for referral.

Alert: As of 2019, all previous colonoscopy reports PLUS histology need to be sourced AND attached prior to colonoscopy as per new MBS item numbers and new polyp surveillance guidelines.
Referrals will be sent back if this information is not provided.

<SURVEILLANCE / SCREENING COLONOSCOPY> SURVEILLANCE / SCREENING COLONOSCOPY	<SURVEILLANCE / REPEAT GASTROSCOPY> SURVEILLANCE / REPEAT GASTROSCOPY	
Date of last colonoscopy: 
      (Attach last report including histology)

IBD surveillance group (1,2 or 3): 

Ulcerative Collitis (Y/N): 

Crohn's (Y/N):                                         Diagnosed: 

Primary sclerosing cholangitis (Y/N):      Diagnosed:

Family history risk screening category (1,2, or 3): 

Familial hereditary syndrome (Y/N): 
      Details: 

Colorectal cancer surveillance (Y/N):     
      Diagnosed:

Other: 	Date of last gastroscopy: 
      (Attach last report including histology)

Barrett's oesophagus (Y/N):    Lynch (Y/N): 

Gastric ulcer (Y/N):    Eosinophilic Oesophagitis (Y/N): 

APC (Y/N):                 Duodenal ulcer (Y/N): 

Varices (Y/N): 

      Oesophageal (Y/N): 

      Gastric (Y/N): 

Familial hereditary syndrome (Y/N): 
      Details: 

Previous upper GI cancer (Y/N):
      Diagnosed: 
Previous gastric or bariatric surgery (Y/N):     Date: 

Previous therapeutic procedures (Y/N):          Date: 
(EMR, RFA, Upper GI surgery)

Other: 

FOR DIAGNOSTIC SCOPE CRITERIA CONTINUE BELOW

REFERRAL REQUIREMENTS:
Please indicate all that apply & provide copy of recent endoscopic procedures (date, report, histology)

<DIAGNOSTIC LOWER ENDOSCOPY> DIAGNOSTIC LOWER ENDOSCOPY	<DIAGNOSTIC GASTROSCOPY> DIAGNOSTIC GASTROSCOPY	
COLONOSCOPY (Y/N):    FLEX SIGMOIDOSCOPY (Y/N): 

Indication:   Symptoms and Investigations

Positive iFOBT (Y/N):
(attach results)

Iron Deficiency (Y/N): 

      With anaemia (Y/N):   (attach results) -> Duration: 

Hb	
	
MCV	

Ferritin	
	
TSAT	

      WITHOUT anaemia (Y/N):      -> Duration: 

Anaemia (other) (Y/N):     Details: 

Rectal bleeding (Y/N):      Duration: 

DRE finding (Y/N):            Details: 

Age ≥60 years (Y/N): 

Change in bowel habit (Y/N): 

      Constipation (Y/N):      Duration: 
      Diarrhoea (Y/N):          Duration: 

C. difficile (Y/N): 
      (attach results)

PCR bac/rival/parasite (Y/N): 
      (attach results)

Abdominal pain (Y/N):      Duration: 

      Pain characteristics: 

Possible IBD (Inflammatory bowel disease) (Y/N): 

      Calprotectin (Y/N):      CRP (Y/N): 

Unintentional weight loss (≥10% of body weight)(Y/N):

Amount	
	
Over what time	

Current weight	
	
BMI	

Primary cancer of unknown origin (Y/N): 

Abnormal imaging suggestive of colorectal cancer (Y/N):
      (attach report)

Palpable mass (or on sigmoidoscopy) (Y/N): 

      Abdominal (Y/N):      Rectal (Y/N):            	Indication:   Symptoms and Investigations

GORD(Y/N):    -> Not responsive to PPI treatment (Y/N): 

Dyspepsia (Y/N):  
       -> Not responsive to PPI and/or H.pylori treatment (Y/N):

Malaena (Y/N): 

Haematemesis (Y/N): 

Upper abdominal pain (Y/N): 

      Site:            Duration: 

Iron Deficiency(Y/N): 

      With anaemia(Y/N):   (attach results) -> Duration: 

Hb	
	
MCV	

Ferritin	
	
TSAT	

 
      WITHOUT anaemia (Y/N):      -> Duration: 

Anaemia (other) (Y/N):     Details: 

Microcytosis (Y/N):   Details: 

Abnormal blood test: FBC (Y/N):   ELFT (Y/N):   (attach results)

B12 deficiency (Y/N):      Duration: 

Atopy (Y/N):   

Suspected malignancy:

   Age ≥ 55 years (Y/N):         Dysphagia (Y/N): 

   Loss of appetite (Y/N):        Early satiety (Y/N): 

   Nausea/Vomiting (Y/N):      Odynophagia (Y/N): 

   Suspected upper GI malignancy on imaging (Y/N): 
      (attach report)

   Unintentional weight loss (≥10% of body weight)(Y/N): 
      
Amount	
	
Over what time	

Current weight	
	
BMI	

Known:

   Barrett's oesophagus (Y/N):        Atrophic gastritis (Y/N):

   Gastric dysplasia (Y/N):              Coeliac disease (Y/N): 

   Gastric intestinal metaplasia (Y/N): 

   Oesophagitis (Y/N):   -> Grade (A,B,C or D): 

CLINICAL HISTORY
<SelectedPMH>

MEDICATIONS
<SelectedRx>

ALLERGIES
<Reactions>

INTERNAL USE ONLY
‘ Insufficient information to triage. Additional information required - return to referring doctor
‘ Sufficient information provided but NOT suitable to proceed directly to procedure
         Redirect to:     ‘ Gastroenterology clinic     ‘ IBD clinic      ‘ Other: ...........................................
‘ Sufficient information provided -> proceed directly to procedure:
                                 ‘ Colonoscopy     ‘ Gastroscopy     ‘ Flexible Sigmoidoscopy
Suggested Triage:     ‘ Category 4     ‘ Category 5     ‘ Category 6
      If surveillance scope:      Due: ....../....../.......      ‘ Cat 4     ‘ Cat 5     ‘ Cat 6
      Recommended bowel prep:     ‘ Standard     ‘ Enhanced     ‘ Clinic review required for bowel prep education
      Additional requirements:          ‘  PAC medical review    ‘ Anti-coagulation management     ‘ Diabetic management

Comments:      .............................................................................................................................................................

Date reviewed: ....../....../......      Reviewed by: ..................................................... Signature: .....................................