Metro South Health					             AFFIX Identification Label Here
Direct Access Endoscopy (DAE)                                                 (For Hospital Use)
Referral Form

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

(V1.1 MD, Reviewed: Nov 2018)

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

Date: <<Miscellaneous:Date>>

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Thank you for seeing <<Patient Demographics:Title>> <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>

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

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PATIENT DETAILS
RE: <<Patient Demographics:Full Name>>  D.O.B.:<<Patient Demographics:DOB>> 
Gender: <<Patient Demographics:Sex>>
Address:<<Patient Demographics:Full Address>>
Phone (Home):<<Patient Demographics:Phone (Home)>>
Mobile:<<Patient Demographics:Phone (Mobile)>>
Medicare No.: <<Patient Demographics:Medicare Number>> Expiry: <<Patient Demographics:Medicare Expiry Date>>
DVA No: <<Patient Demographics:DVA Number>>
Preferred Language: <<Preferred Language>>    Is an Interpreter required: <<Is an Interpreter required>>
Ethnicity: <<Patient Demographics:Ethnicity>>

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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, 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 patient have an increased risk of anaesthesia>>
If Yes, please provide details: <<If yes, increased risk of anaesthesia provide details>>
History of Surgical Complications:  <<Does patient have history of surgical complications>>
If Yes, please provide details: <<If yes, please provide details:>>
Strong family history of gastrointestinal cancer:  <<Does patient have strong FH gastrointestinalcancer>>
If Yes, please provide details: <<If Yes please provide details:>>

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MEDICAL HISTORY

Age: <<Patient Demographics:Age>>

Weight:<<Clinical Details:Measurements>>
Height: <<Clinical Details:Measurements>>
BMI: <<Clinical Details:Measurements>>
BP Observations: <<Clinical Details:Measurements>>
PR bleed, visible blood on stool: <<Does patienthave 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>>
<<If Yes to iron deficiency/anaemia>>
Positive FOBT: <<Does your patient a positive FOBT?>>
<<If Yes to positive FOBT, please attach reports >>
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 patient have chronic/relapsing vomiting/naus>>
Dysphagia/relevant swallowing disorder: <<Does patient have dysphagia/relevant swallowing >>
Has the patient had a previous colonoscopy and/or gastroscopy? <<Has patient had previous colonoscopy/gastroscopy>>
Details: <<If yes provide details:>>
Procudure: 
<<Please provide procedure details:>>
Is the referral for surveillance of a known condition or from a previous pathology? <<Referralfor surveillance of known cond or prev path>> 
Reason: <<If yes, please provide reason>>

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

<<If Yes, please describe symptoms, conduct and>>

Past History: 
Active: <<Clinical Details:History List>>
Inactive: <<Clinical Details:History List>>

Current Medication: <<Clinical Details:Medication List>>

Allergies: <<Clinical Details:Allergies/Adverse Reactions>>

Smoking: <<Clinical Details:Smoking>>

Alcohol: <<Clinical Details:Alcohol>>

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REFERRING DOCTOR DETAILS
Name: <<Doctor:Name>>
Qualifications: <<Doctor:Qualifications>>
Provider Number: <<Doctor:Provider Number>>
Practice Name: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>

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VERIFICATION
Electronically Signed: <<Doctor:Name>>
<<Miscellaneous:Date>>

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

______________________________________________________________________________
RE: <<Patient Demographics:First Name>> DOB: <<Patient Demographics:DOB>>E:<PtFullName> DOB: <PtDoB>
                                                                                                                        V1.1 MD, Nov 2018