General Practitioner Referral Form Endoscopy
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1MATER MISERICORDIAE UNIVERISTY HOSPITAL
GENERAL PRACTITIONER REFERRAL FORM
ENDOSCOPY / GASTROENTEROLOGY
Patient Name:
Date of Birth:
/
/
Addresses:
Contact Telephone:
Patient Age:
Referring GP:
Previous Endoscopy / Colonoscopy?
Address:
Date:
/
/
Hospital:
Medical Record Number:
Medication:
Warfarin
Clopidogrel
Dabigatran
MAOI
Telephone:
Diabetic:
No
Insulin
No Insulin
SYMPTOMS
UPPER GI
Other Indication:
COLORECTAL SYMPTOMS
Pain
Abdominal / Rectal Mass
Dyspepsia
Iron Deficiency Anaemia
Reflux / Heartburn
Rectal Bleeding
>6 weeks
Dysphagia
<6 weeks
Haematemesis
Loose Stools or Diarrhoea
>6 weeks
Melaena
<6 weeks
Nausea / Vomiting
IBD Assessment
Anaemia
COLORECTAL SCREENING
Weight Loss
Average Risk (Age<50)
Barrett’s Oesophagus
History of Adenomatous Polyps
Duodenal Biopsy
History of Colorectal Cancer
Family History
G.P. Signature:
IBD Surveillance
Medical Council Number:
HOSPITAL USE ONLY
Date Received:
/
/
Date Reviewed:
/
/
Appointment:
/
/
OGD
Colonoscopy
Left Colon
UBT
OPD
Priority 1
Priority 2
Consultant Signature:
Medical Council Number:
Fax to 01 803-4770 or post to GI Unit, Mater Misericordiae University Hospital, Eccles Street, Dublin 7
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