Gastrointestinal Endoscopy
Referral Form
Please fax referral to 8345 7378. Incomplete referrals will be returned
to the referring doctor.
For any booking enquiries phone 8345 6015.
For clinical queries please contact the Gastroenterology
Endoscopy Registrar via switchboard on 8345 6666.	Patient details
Name:  <<Patient Demographics:Full Name>>
Date of Birth:  <<Patient Demographics:DOB>>
Gender:  <<Patient Demographics:Gender>>
Address:  <<Patient Demographics:Address>>
Suburb:  <<Patient Demographics:City>>
Postcode:  <<Patient Demographics:Postcode>>
Preferred phone number:  <<Patient Demographics:Phone (Home)>>
Additional phone numbers:  
Medicare Number:  <<Patient Demographics:Medicare Number>>
Private health fund details (if applicable): <<Private Health Fund details (if applicable)>>	
Please complete this form in full. Incomplete forms will be returned to the requesting clinician.
Referring doctor details
Name:  <<Doctor:Name>>	Suburb:  <<Doctor:City>>	o  GP
Practice name: <<Practice:Name>>	Postcode:  <<Doctor:Postcode>>	o  Specialist Private Rooms
Referring doctor provider number:  <<Doctor:Provider Number>>	Phone:  <<Doctor:Phone>>	o  Emergency Department WH
Practice Address:  <<Doctor:Address>>	Fax:  <<Doctor:Fax>>	o  Specialist Clinic Western Health
Date: <<Miscellaneous:Date (short)>>		      Clinic Name:  	
		o  Other Department Western Health: 	
		o  Inpatient unit Western Health: 	
		o  Other hospital: 		
Interpreter required   o  Yes      Language (specify): 		
Diagnostic Lower GI Endoscopy Request      
o  Colonoscopy	o  Flexible Sigmoidoscopy
Indication A: Symptoms and Investigations
o  Positive iFOBT (Attach FOBT results)
	o  NBCSP
	o  Not NBCSP
o  Anaemia: (provide results below or attach results)
o  Rectal bleeding - months duration: 	
o  Age ≥ 60 years
o  Change in bowel habit
	o  Constipation - months duration: 	
	o  Diarrhoea - months duration: 	
	o  Constipation & diarrhoea - months duration: 	
o  Abdominal pain - months duration: 	
o  Possible IBD (Inflammatory Bowel Disease)
o  Unintentional weight loss (≥10% of body weight)
o  Primary cancer of unknown origin
o  Abnormal imaging suggestive of colorectal cancer
o  Palpable mass (or on sigmoidoscopy) 
	o  Abdominal	o  Rectal
o  Hb 	 o  MCV 	 o  Ferritin 	
o  Calprotectin 	 o  CRP
Clinical Notes: 		Diagnostic Upper GI Endoscopy Request
o  Gastroscopy 
Indication A: Symptoms and Investigations
(tick all that apply and provide copy of relevant results)
Bleeding:
o Haematemesis	o  Melaena
o  Iron deficiency anaemia (attach Hb and Ferritin level)
o  Abnormal blood test (please check): o  low Hb / o  low ferritin / 
    o  microcytosis / o  hypochromasia / o  raised platelets 
Suspected malignancy:
o  Age ≥ 55 years	o  Dysphagia
o  Suspected malignancy on imaging (attach report)
o  Nausea / vomiting, persistent (≥ 6 weeks)
o  Loss of appetite	o  Early satiety
o  Unexplained weight loss (≥10% of body weight)
o  Known: o Barrett’s oesophagus / o gastric intestinal metaplasia / 
	o gastric dysplasia / o atrophic gastritis / (check all that apply)
o  Family history of upper GI cancer in 1st degree relative 
Other symptoms:
o  GORD	o Not responsive to PPI	o  Recent onset
o  Dyspepsia	o Not responsive to PPI and/or H. pylori treatment (please circle)
o  Upper abdominal pain
o  Suspected coeliac disease (with positive serology – attach results
o  Other:  		
Indication B: Colonoscopy for surveillance or screening
Please refer to NHMRC surveillance guidelines
Date of last colonoscopy 	
Must attach last gastroscopy report and histology report
o  Adenoma surveillance risk category:  o A   o B   o C   o D
o  IBD Surveillance group:   o  1   o  2   o  3
	IBD type:   o  Ulcerative colitis    o  Crohn’s 
	Date of IBD Diagnosis: 	
	Primary sclerosing cholangitis date of diagnosis: 	
o  Family history screening risk category:   o  1   o  2   o  3
	Familial Hereditary Syndrome: 	
o  Colorectal Cancer surveillance
	Date of colorectal cancer diagnosis: 	
o  Other: 		Indication B: Gastroscopy for surveillance or screening
Date of last gastroscopy 	
Must attach last colonoscopy report and histology report
o  Barrett’s oesophagus	o  Gastric ulcer
o  Varices	o  oesophageal	o gastric 
o  Oesophagitis	o Severe erosive (LA Grade C-D)	o Eosinophilic
o  Gastric dysplasia	o  Gastric intestinal metaplasia
o  Previous upper GI cancer (Date of diagnosis 	)
o  Previous therapeutic procedure (EMR, RFA, upper GI surgery)
	(Date of procedure 	)
o  Syndrome:	o  APC	o  Lynch
o  Other: 		
Indication C: Therapeutic Colonoscopy
o  Haemorrhoid banding	o  Colon stenting
o  EMR / polypectomy for	o  APC
	colorectal polyp ≥ 2 cm	o  Dilatation
o  EMR / polypectomy for	o  APC for radiation proctitis
	colorectal polyp < 2 cm	o  Other: 	
Clinical Notes: 		Indication C: Therapeutic Gastroscopy
o  Barrett’s with dysplasia	o  Varices (oesophageal)
o  Varices (gastric)	o  Dilatation	o  Gastric polyp(s)
o  Duodenal polyp(s)	o  Upper GI stenting	o  PEG insertion
o  Other: 	

Clinical Notes: 		

Gastrointestinal Endoscopy
Referral Form continued
	Patient details
UR number:	<<UR Number>>
Surname:	<<Patient Demographics:Surname>>
First name:	<<Patient Demographics:First Name>>
Date of birth:	<<Patient Demographics:DOB>>	
  	
Indication D:  Inadequate bowel preparation at recent colonoscopy
o  Repeat colonoscopy due to inadequate bowel preparation.
	See original endoscopy referral form for clinic details.	Indication D:  Pre-Operative Assessment Gastroscopy

o  Known upper GI cancer	o  Hiatus Hernia
o  Anti-reflux surgery	o  Other: 	
o  Bariatric surgery		
ERCP Request: Attach relevant imaging report and blood tests
o  Bile duct stone	o  Biliary stent:
o  Bile duct stricture		o  change	o  removal
o  Tumour/mass lesion  	o  Other: 	
	 causing jaundice 

Clinical Notes: 		EUS Request: Attach relevant imaging report and blood tests
o  Bile duct abnormality	o  Assessment of subepithelial lesion
o  Pancreatic duct abnormality	o  Other lesion for FNA
o  Pancreatic cyst	o  Pseudocyst drainage
o  Pancreatic mass lesion
o  Ampullary lesion	o  Other: 	
Clinical Notes: 		
Additional clinical information required: 
Please include details about risk factors:
o  None

o  Family history of gastro-intestinal malignancy 
	Details: 	
o  Current smoker	o  Alcohol excess
o  Recreational drug use	o  Obesity
Other relevant information: 		
Additional relevant medical details:
o  Diabetes:   o  Type  I	o  Type II	o  Insulin requiring
o  No allergies to medication
o  Allergies: 	
o  Previous malignancy:  	
o  Current malignancy: 	
	
Anaesthetic Risk
Please indicate if patient suffers from any of the following:
o  BMI >40
o  Symptomatic ischaemic heart disease
o  Valvular heart disease or congestive heart failure
o  Severe obstructive sleep apnoea
o  Respiratory disease requiring oxygen therapy
	or limiting patient’s day to day activities (NYHA class 3)

o  Chronic kidney disease requiring dialysis or pre-dialysis
o  Patients with neuromuscular disorders
	(e.g. myasthenia gravis, muscular dystrophy, cerebral palsy)
o  Known bleeding disorder
o  Known prior severe reaction to anaesthesia e.g. malignant hyperthermia,
	suxemethonium apnoea, severe post-operative nausea or vomiting or 
	known difficult airway
	
Note: If yes to any of these indicators, patient is not suitable for Sunbury Day Hospital	
Anti-Coagulation / Anti-Platelet Therapy* 
o None
	Can it be stopped?	Can it be stopped?
o Aspirin*	o  Yes   o  No   o  Unsure	o Rivaroxaban	o  Yes   o  No   o  Unsure
o Clopidogrel	o  Yes   o  No   o  Unsure	o Dabigatran	o  Yes   o  No   o  Unsure
o Ticagrelor	o  Yes   o  No   o  Unsure	o Apixaban 	o  Yes   o  No   o  Unsure
o Prasugrel	o  Yes   o  No   o  Unsure	o Low Molecular	o  Yes   o  No   o  Unsure
o Warfarin	o  Yes   o  No   o  Unsure		Weight Heparin
		o Other	o  Yes   o  No   o  Unsure
Comments: 	
* Note that aspirin can nearly always be continued	
Risk factors for poor bowel preparation for colonoscopy:
Please indicate if patient suffers from any of the following:
o  Constipation	o  Stroke	o  Tricyclic antidepressant
o  Obesity	o  Chronic opioid use
o  Diabetes	o  Parkinson’s Disease