Inpatient by alicejenny

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									GASTROSCOPY REFERRAL FORM (Non-Emergency)
Please complete all appropriate sections of this form. Incomplete forms will result in a delay in listing
          and may be returned to the referrer. This form MUST be signed by the referrer.
                      For out-patient referrals please send completed forms to:
     Endoscopy booking, WAHT, Grange Road, Weston-super-Mare, BS23 4TQ - Tel 01934 881021
               For in-patients please deliver form direct to Endoscopy Department.

 1. PATIENT DETAILS                (Please repeat name and hosp no. overleaf if to be faxed)

 MRN / NHS Number:                                       Patient Address:
 Surname:

 Forenames:

 Date of Birth:
 Sex:     M/F                                            Patient Tel. No:
 GP Name:                                                Inpatient: Ward:
                                                          Ward Ext. No:
 GP Address:                                             Consultant:

                                                         Ref Dr & Bleep:

 GP Tel. No:                                             Signature:
 Signature:
 Date of referral:                                       Date of referral:

 2. PROCEDURE REQ’D                     (Please tick)

      OGD– please follow referral pathway overleaf                           Breath test

  Other please specify
 For follow up procedures, please indicate if PPI’s are to be stopped : Yes                         No
 For GP referrals: Urgent (< 2 weeks)  For Consultants -
                    Routine              Indicate timeframe:
 Clinical details:




 3. BOOKING DETAILS (Endoscopy Use Only) Request received:
                Inpatient                                 Outpatient
 Date booked:                          Listing letter sent:
 By whom:                              Appointment booked:
 Procedure due:                        At (time):
 At (time):                            Transport booked:
                                       By whom:
 Validation date:                                        Validating clinician:
 Accepted:       Deferred:        Rejected:           Comments:

  CR_END_019_1.3_OGDReferral                            January 2010                         Page 1 of 2
IF FAXED, PATIENT NAME:                                             HOSP NO:

4. GASTROSCOPY REFERRAL PATHWAY

A. Suspected cancer alarm symptoms                  YES  If outpatient, please send via fast
 Chronic GI bleeding                               track (two week wait) route Cancer services
 Progressive unintentional weight loss             Weston General Hospital
 Dysphagia
 Suspicious barium meal                            NO      Go to section 4B
 Epigastric mass

B. Urgent Referral Symptoms                   YES NOIf no go to section C
 Dyspepsia with acute GI bleeding             Persistent vomiting
 > 55 with unexplained and persistent recent onset dyspepsia
 Iron deficiency anaemia     Hb:        MCV:        Ferritin:      Date:


C. Routine Referral Symptoms
(If inpatient triaged as routine, will be booked as outpatient)
 Recent onset reflux over 55 years
Patients with uncomplicated reflux under age 55 should be managed as per NICE
guidelines.
 ? Coeliac / Malabsorption
 New Dyspepsia – (recurrent epigastric pain, bloating, nausea and vomiting)
Patients under 55 will only be endoscoped for dyspepsia if they have received at least 4 weeks PPI
and been tested and treated for H. pylori if indicated or where there is a heightened risk: eg (Family
history, pernicious anaemia, prev gastric surgery, prev gastric ulcer or continuing need for NSAIDS)
  Hp serology or Breath Test (Date:              ). Eradication therapy (Date:                 ).
  1/12 PPI treatment (Date:          ).
Further information/ results of any other relevant investigations:




5. MEDICAL/DRUG HISTORY

ANTICOAGULANT/ANTIPLATELET                          ALLERGIES (including food, drugs &
TREATMENT: (refer to guidelines)                    materials):
 Indication:
Warfarin Other (specify):
 Aspirin    Clopidogrel

Morbid obesity?: Yes             Poor Mobility?: Yes                  Transport Req? Yes 
Translator is needed?  Yes                      Which language:
Visual impairment? Yes           Hearing impairment? Yes 
IDDM                              Liver disease                     Bleeding disorders
NIDDM                             Previous gastric surgery          MI < 6 weeks ago
Any known infections?              MRSA                              HIV 
HBV/HCV                           Infectious diarrhoea: Clos Diff     Other
Further details:

Please attach an accompanying letter if you feel this would be beneficial.

CR_END_019_1.3_OGDReferral                          January 2010                          Page 2 of 2

								
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