Gastrointestinal procedure request form

Patients referred to the combined Endoscopy Service will be triaged for endoscopic procedures, depending on clinical requirements and best available booking times. Low-risk day procedures are being performed at Fremantle hospital.

Admission & procedure details
Admission date
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Patient details
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Language
Interpreter required
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Procedure request
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Reason for referral
Abdominal pain
Abnormal imaging
Abnormal Liver function / cirrhosis
Change in bowel habit
Diarrhoea (chronic > 6/52)
Dyspepsia / reflux
Dysphagia
Family history of bowel cancer
(specify family member/s and aged diagnosed with bowel cancer)
Fe def Anaemia for investigation
History of colorectal cancer or polyps
Persistent vomiting and nausea
Follow-up eg varices, polyps, Barrett’s
Planned surgery or procedure specify
Positive celiac serology
Positive FOBT
PR Bleeding
Suspected IBD
Weight loss unexplained
Relevant Medical History and Risk Factors For Procedure (Please give details indicating severity, type)
Medical History
Please indicate if the patient has a history of any of the following:





Is patient using any anticoagulants and or antiplatelets?
Is the patient well enough for bowel prep at home if required?
Clinical details (include previous findings and relevant information): E.g. Previous GI surgery / history (Specify)
Referring Doctor