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Upper GI Endoscopy Referral Form - InHealth Group

This document is a gastroscopy request form for a community endoscopy service in Gloucestershire. It requests patient details, referral details, and medical information including reason for the endoscopy request, relevant clinical history, diabetes status, use of medications like warfarin and clopidogrel, H. pylori status, use of NSAIDs and PPIs, and preferred location for the procedure. Patients presenting with certain "alarm symptoms" should be referred to an urgent 2-week wait service instead of this direct access community endoscopy service.

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Abdullahi Ahmed
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492 views2 pages

Upper GI Endoscopy Referral Form - InHealth Group

This document is a gastroscopy request form for a community endoscopy service in Gloucestershire. It requests patient details, referral details, and medical information including reason for the endoscopy request, relevant clinical history, diabetes status, use of medications like warfarin and clopidogrel, H. pylori status, use of NSAIDs and PPIs, and preferred location for the procedure. Patients presenting with certain "alarm symptoms" should be referred to an urgent 2-week wait service instead of this direct access community endoscopy service.

Uploaded by

Abdullahi Ahmed
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Inhealth Endoscopy Ltd – Gloucestershire Direct Access Community Endoscopy Service

Gastroscopy Request Form

Please fax this referral to 08454 370343

ALARM SYMPTOMS: Patient with any of these symptoms should be referred into appropriate 2WW
service
Dysphagia
Epigastric mass
Unexplained, persistent new dyspepsia, aged >55 yrs
Unintentional weight loss
Persistent vomiting
Iron deficiency anaemia with no obvious cause
Obstructive jaundice

Patient Details Referrer details

Surname: Referring GP:


Forename: Usual GP:

Address: Address:

Postcode: Postcode:
Home tel: Tel:
Daytime tel: Fax:
Date of Birth
NHS Number:

INVESTIGATION REQUEST DETAILS


Current Request
Gastroscopy (Upper GI)
Patient had previous endoscopy? Yes No Date (DD/MM/YYYY):
If yes, what type of previous endoscopy? Gastroscopy Flexi Sigmoidoscopy Colonoscopy
Reason for request:

Relevant clinical history:

Page 1 of 2

Referral template for Upper GI – Gloucestershire – IEL 20130902


Inhealth Endoscopy Ltd – Gloucestershire Direct Access Community Endoscopy Service
Gastroscopy Request Form

MEDICAL INFORMATION
Note: If the patient requires sedation, they must have an escort home and have observation overnight
Does the patient have capacity to give informed consent? Yes No
Yes No
Is this patient diabetic? If yes, is the patient Insulin dependent?
Yes No
Is the patient on Warfarin? Yes No Duration:
Is the patient on Clopidogrel? Yes No Duration:

If you have answered ‘yes’ to any of the questions above, please ensure that you include any additional relevant
clinical information above.

H Pylori status: Positive Negative Not known


NSAID: Yes No Duration (weeks): Must continue: Yes No
PPI/H2 antagonist: Yes No Duration (weeks): Patient responded Yes No

PREFERRED ENDOSCOPY LOCATION (please circle the preferred location)

Cirencester

Page 2 of 2

Referral template for Upper GI – Gloucestershire – IEL 20130902

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