Wide Bay Hospital and Health Service
GASTROENTEROLOGY
SERVICES REFERRAL

Referral to: 
<<Referral to>> - <<if other please state>>	RE: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Family name: <<Patient Demographics:Surname>>
Given names: <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>
Address: <<Patient Demographics:Address>>
Contact phone - home: <<Patient Demographics:Phone (Home)>> work: <<Patient Demographics:Phone (Work)>> mobile: <<Patient Demographics:Phone (Mobile)>>
Date of birth: <<Patient Demographics:DOB>>      Sex: <<Patient Demographics:Gender>>	

Date of referral: <<Miscellaneous:Date (short)>>           Provider No: <<Doctor:Provider Number>>
Referring GP: <<Doctor:Name>>                    GP practice: <<Practice:Name>>
Email: <<Doctor:E-mail>>
.................................................................................
PATIENT DETAILS
Medicare number: <<Patient Demographics:Medicare Number>> Expiry: <<Patient Demographics:Medicare Expiry Date>>
Private health: <<Private health?>>   Fund-name: <<Patient Demographics:Health Insurance>>   Fund number: <<Private health fund number>>
Interpreter required? <<Patient Demographics:Requires Interpreter>> Language: <<Patient Demographics:Language Preferred>> 
.................................................................................
REFERRAL
Referred for - Clinic: <<Referred for - Clinic>>   Gastroscopy: <<Referred for - Gastroscopy>>   Colonoscopy: <<Referred for - Colonoscopy>>   Flexible sigmoidoscopy: <<Referred for - Flexible sigmoidoscopy>>
Brief clinical summary:
<<Brief clinical summary>>
.................................................................................
PATIENT CLINICAL DETAILS
Diabetes - Type I: <<Diabetes - Type I>>   Type II: <<Type II>>   Requires insulin: <<Requires insulin>>
Obesity: <<Obesity>>   Alcohol excess: <<Alcohol excess>>   Current smoker: <<Clinical Details:Smoking>>   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
<<Clinical Details:History List>>

Medications
<<Clinical Details:Medication List>>

Allergies
<<Clinical Details:Allergies/Adverse 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: .....................................