Metro South Health					             AFFIX Identification Label Here
Direct Access Endoscopy (DAE)                                                 (To Be Completed By Facility)
Referral Form

Central Referral Hub
PO Box 4195, Eight Mile Plains, QLD 4113
Phone: 1300 364 155     Fax: 1300 364 248

(V1.1 BP, Reviewed: Nov 2018)

Name of Specialist Referring To (if applicable): <Name of Specialist Referring To:> 
Hospital: <Hospital>

<TodaysDate>

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Thank you for seeing <PtTitle> <PtFirstName> <PtSurname>. 

Requested Procedure: <Requested Procedure:>
DAE Criteria: <DAE Criteria:>
The consent information have been explained and provided to the patient: <The consent information have been explained and provided to the patient:>

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PATIENT DETAILS
RE: <PtFirstName> <PtSurname>  D.O.B.: <PtDoB>
Gender: <PtSex>
Address:<PtStreet>
<PtCity> <PtPostcode> <PtState>
Phone (Home):<PtPhoneH>
Mobile:<PtPhoneMob>
Medicare No.: <PtMCNo> <PtMCLine>  Expiry: <PtMCExpiry>
DVA No: <PtDVANo>
Preferred Language: <Preferred Language>     Is an Interpreter required: <Is an Interpreter required>
Ethnicity: <PtEthnicity>

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RELEVANT CO-MORBIDITIES
Cardiovascular: <Does your patient have a Cardiovascular condition?>
If Yes, please provide details: <If yes to Cardiovascular please provide details:>
Respiratory: <Does your patient have a Respiratory condition?>
If Yes, please provide details: <If yes to Respiratory condition please provide details:>
Renal: <Does your patient have a Renal condition?>
If Yes, please provide details: <If yes to Renal condition please provide details:>
Diabetes:  <Does your patient have a Diabetes?>
If Yes, please provide details: <If yes to Diabetes please provide details:>
Increased Risk of Anaesthesia:  <Does your patient have an increased risk of anaesthesia?>
If Yes, please provide details: <If yes to increased risk of anaesthesia please provide details:>
History of Surgical Complications:  <Does your patient have a history of surgical complications?>
If Yes, please provide details: <If yes to a history of surgical complications please provide details:>
Strong family history of gastrointestinal cancer:  <Does your patient have a strong family history of gastrointestinal cancer?>
If Yes, please provide details: <If yes to strong family history of gastrointestinal cancer please provide details:>
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MEDICAL HISTORY
Age: <PtAge>

Weight/height/BMI/BP Observations: <Observations>

PR bleed, visible blood on stool: <Does the patient have PR bleed, visible blood on stool?>
<If yes to PR bleed, visible blood on stool>
Iron deficiency/anaemia (Post menopausal, not menorrhagia or dietary causes): <Does your patient have Iron deficiency/anaemia (Post menopausal, not menorrhagia or dietary causes)?>
<If Yes to iron deficiency/anaemia>
Positive FOBT: <Does your patient a positive FOBT?>
<If Yes to Positivie FOBT please attached report and indentify pathology provider>
Source:  <If Yes to positive FOBT, please provide source?>
Abdominal pain/discomfort: <Does your patient have abdominal pain/discomfort:>
Location in abdomen (quadrant/central/etc): <If yes to abdominal pain, please provide location>
Abnormal GIT Imaging: <Has your patient had abnormal GIT Imaging? If Yes please attach report>
Suspected coeliac disease: <Does your patient have suspected coeliac disease? If Yes please attach coeliac screen>
Chronic/relapsing vomiting or nausea: <Does your patient have chronic/relapsing vomiting or nausea?>
Dysphagia/relevant swallowing disorder: <Does your patient have dysphagia/relevant swallowing disorder>

Has the patient had a previous colonoscopy and/or gastroscopy? <Has the patient had a previous colonoscopy and/or gastroscopy?>
Details: <If Yes please provide details:>
Procudure: 
<Please provide procedure details:>
Is the referral for surveillance of a known condition or from a previous pathology? <Is the referral for surveillance of a known condition of from a previous pathology?>
Reason: <If yes, please provide reason>

Is the referral for a patient experiencing any other gastrointestinal symptoms? <Is the referral for a patient experiencing any other gastrointestinal symptoms?>

<If yes, please describe symptoms, conduct and attach ELFT, FBC, CRP and ESR in addition to any required investigations indicated>

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MEDICAL HISTORY
Active: <PMHActive>
Inactive: <PMHInactive>
Relevant Investigations: <Ix>

Current Medication: <CurrentRx>

Allergies: <Reactions>

Smoking: <SmkHx> <SmkStatus>

Alcohol: <AlcHx>

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REFERRING DOCTOR DETAILS
Name: <DrName>
Qualifications: <DrQualifications>
Provider Number: <DrProviderNo>
Practice Name: <Practice>
Address: <DrAddress>
Phone: <DrPhone>
Fax: <DrFax>

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VERIFICATION
Electronically Signed: <DrName>
<DayAndDate>

Please check that ALL sections on this form have been completed before submitting. 

For more information, please refer to: 
www.metrosouth.health.qld.gov.au/dae
Or phone the Metro South Central Referral Hub at 1300 364 155 for any enquiries regarding referrals