Request for Direct Access
Gastrointestinal Endoscopy (Adult)	

Referral for:	<Referral for:>	
Reason for Referral (must select one):	<Reason for Referral (must select one):>	If other please specify: <If other please specify:>	
For clinical assessment or other procedures (e.g. ERCP, EUS) please use the CRS General Adult Outpatient
form. For guidance on referral guidelines, refer to the HealthPathways or Referral Access Criteria websites.
Patients who require immediate attention (i.e. within 7 days) should NOT be referred via the Central Referral Service – contact the Gastroenterology service at the nearest site for advice.
For referrals to WACHS hospitals, please forward directly to the relevant site.

Patient Details	
First name:	<PtFirstName>	Family Name:	<PtSurname>	
Maiden Name/Alias:	<Patient Maiden Name/Alias>	
DOB:	<PtDoB>	Sex:	<PtSex>	
Address:	<PtStreet>	
Suburb:	<PtCity>	Postcode:	<PtPostcode>	
Home no:	<PtPhoneH>	Work no:	<PtPhoneWk>	
Mobile:	<PtPhoneMob>	Email:	<PtEmail>	
Medicare no:	<PtMCNo>	Ref:	<PtMCLine>	Expiry:	<PtMCExpiry>	
Next of Kin:	<NOKName>	Contact no:	<NOKContact>	
Interpreter required:	<Is an interpreter required?>	Language:	<Patient's main language spoken?>	
Indigenous status:	<Patient's Indigenous status:>	
Patient available at 
short notice (<3 days):	<Patient available at short notice (3 days)?:>	

Referrer Details	
Name:	<DrName>			
Provider No.	<DrProviderNo>			
Telephone No.	<DrPhone>			
Fax No.	<DrFax>			
Address	<DrAddress>			
				
Date	<TodaysDate>	Signature		

Lower GI indications
for endoscopy: 
(MUST tick at least one 
box and attached relevant
evidence/provide comment
as indicated if referring for
colonoscopy or referral
will be returned) <Lower GI indications for endoscopy: (MUST tick at least one box and attached relevant evidence/provide comment as indicated if referring for colonoscopy or referral will be returned)>		<Rectal bleeding (multiple occurrences or continuous) for >4 weeks (specify time and no. of episodes below)> Rectal bleeding (multiple occurrences or continuous) for >4 weeks (specify time and no. of episodes below)	
		<+iFOBT where a colonoscopy has not been performed within last 2 years (attach results)> +iFOBT where a colonoscopy has not been performed within last 2 years (attach results)	
		<Altered bowel habit >6 weeks AND in presence of alarm symptoms (provide description and must select at least one alarm symptom below)> Altered bowel habit >6 weeks AND in presence of alarm symptoms (provide description and must select at least one alarm symptom below)	
		<Altered bowel habit >6 weeks AND age>=45 (provide description)> Altered bowel habit >6 weeks AND age>=45 (provide description)	
		<Diarrhoea >6 weeks with negative stool culture (attach MC&S results)> Diarrhoea >6 weeks with negative stool culture (attach MC&S results)	
		<Unexplained iron deficiency +/- anaemia (attach FBC results)> Unexplained iron deficiency +/- anaemia (attach FBC results)	
		<Mass or abnormal imaging (attach report)> Mass or abnormal imaging (attach report)	
		<After first episode of proven diverticulitis to exclude neoplasm> After first episode of proven diverticulitis to exclude neoplasm	
		<Surveillance procedures required within 12 months (specify reason & attach reports)> Surveillance procedures required within 12 months (specify reason & attach reports)	

Alarm symptoms for
lower GI endoscopy:
(informs triage- tick all that
apply and attach evidence/
provide detail) <Alarm symptoms for lower GI endoscopy: (informs triage- tick all that apply and attach evidence/ provide detail)>		<Persistent rectal bleeding> Persistent rectal bleeding			<Persistent severe abdominal pain> Persistent severe abdominal pain	
		<Unexplained progressive weight loss> Unexplained progressive weight loss			<Unexplained iron deficiency anaemia> Unexplained iron deficiency anaemia	
		<Bloody diarrhoea with negative stool MC&S> Bloody diarrhoea with negative stool MC&S				

Lower GI comments /
evidence to support
indications: 	<Lower GI comments/evidence to support indications:>	

Upper GI Indications
for Endoscopy:
(MUST tick at least one box
and attached relevant
evidence/provide comment
as indicated if referring for
gastroscopy or referral will
be returned) <Upper GI Indications for Endoscopy: (MUST tick at least one box and attached relevant evidence/provide comment as indicated if referring for gastroscopy or referral will be returned)>		<Unexplained iron deficiency +/- anaemia (attach FBC results)> Unexplained iron deficiency +/- anaemia (attach FBC results)	
		<Unexplained recent dyspepsia AND in presence of alarm symptoms (select at least 1 alarm symptom below)> Unexplained recent dyspepsia AND in presence of alarm symptoms (select at least 1 alarm symptom below)	
		<Non-responsive GORD> Non-responsive GORD	
		<Persistent or recurrent (>=4 weeks) dysphagia (specify time and no. of episodes)> Persistent or recurrent (>=4 weeks) dysphagia (specify time and no. of episodes)	
		<Mass or abnormal imaging (attach report)> Mass or abnormal imaging (attach report)	
		<Upper abdominal pain AND unexplained weight loss OR abnormal blood test (describe symptoms and attach results)> Upper abdominal pain AND unexplained weight loss OR abnormal blood test (describe symptoms and attach results)	
		<Persistent nausea/vomiting AND unexplained weight loss OR abnormal blood test (describe symptoms and attach results)> Persistent nausea/vomiting AND unexplained weight loss OR abnormal blood test (describe symptoms and attach results)	
		<Suspected Coeliac disease with positive serology (attach results)> Suspected Coeliac disease with positive serology (attach results)	
		<Known Coeliac disease with no exposure to gluten AND persistent high titres after 12 months OR in presence of alarm symptoms (select at least 1 alarm symptom below)> Known Coeliac disease with no exposure to gluten AND persistent high titres after 12 months OR in presence of alarm symptoms (select at least 1 alarm symptom below)	
		<Pernicious anaemia (serologically diagnosed), asymptomatic at time of diagnosis (attach results)> Pernicious anaemia (serologically diagnosed), asymptomatic at time of diagnosis (attach results)	
		<Surveillance procedures required within 12 months or requested by previous endoscopist (specify reason and attach reports)> Surveillance procedures required within 12 months or requested by previous endoscopist (specify reason and attach reports)	

Alarm symptoms for
Upper GI Endoscopy: (informs triage- tick all that
apply and attach evidence/
provide detail) <Upper GI Indications for Endoscopy: (MUST tick at least one box and attached relevant evidence/provide comment as indicated if referring for gastroscopy or referral will be returned)>		<Gastrointestinal bleeding> Gastrointestinal bleeding			<Dysphagia> Dysphagia	
		<Unexplained progressive weight loss> Unexplained progressive weight loss			<Early satiety> Early satiety	
		<Unexplained iron deficiency anaemia> Unexplained iron deficiency anaemia				

Upper GI Comments/ evidence to support indications 	<Upper GI Comments/ evidence to support indications>	

Medical History and Risk Factors
	Height (cm)	<Patient Height (cm)>	Weight (kg)	<Patient Weight (kg)>	(Estimate if not known)	
<Medical History and Risk Factors>
	<Bleeding disorder (specify below)> Bleeding disorder (specify below)		<Kidney disease (Attach recent U&E)> Kidney disease (Attach recent U&E)		<Pacemaker in situ> Pacemaker in situ	
	<Neurological history (specify below)> Neurological history (specify below)		<Recent surgery (specify below)> Recent surgery (specify below)		<Cardiac stents in situ> Cardiac stents in situ 	
	<Significant lung/airway disease> Significant lung/airway disease		<Obstructive sleep apnoea> Obstructive sleep apnoea		<Implanted defibrillator in situ> Implanted defibrillator in situ	
	<Liver disease (attach recent LFT/INR/platelets)> Liver disease (attach recent LFT/INR/platelets)		<Heart Disease> Heart Disease		For any of above in situ items, 
specify when <For any of above in situ items, specify when:>
<In situ greater than 1 year:> > 1 year    <In situ less than 1 year:> <1 year	
	<Diabetes (please indicate type below)> Diabetes
	Type: <Diabetes type:>		<Previous CVA> Previous CVA			
			<None> None			

Additional Medical
History Details:	<Additional Medical History Details:>	

Special
Considerations: <Special Considerations>
<Significant alcohol history> Significant alcohol
history	<Significant illicit drug history> Significant illicit
drug history	<Significant mental health issues> Significant mental
health issues	<Other social factors e.g. homeless (detail below)> Other social factors e.g. homeless (detail below)	
<Department of Justice patient> Department of
Justice patient	<Nursing home patient> Nursing home
patient			

Other / Comments:	<Special Considerations : Other / Comments:>	

Is the Patient taking any anti-coagulant or anti-platelet medication/s, including Aspirin?
<Is the Patient taking any anti-coagulant or anti-platelet medication/s, including Aspirin?>
If yes, please specify drug and reason (and include any 
relevant documentation from other specialists):		

Current medication:
Please list all medications
patient is currently taking,
or attach summary	<SelectedRx>	

Allergies / Reactions
(inc. latex, tapes etc.):	<Reactions>	<Allergies/Reactions NIL KNOWN> Nil known	

Relevant Investigations - Please provide date and findings, or attach report:	<Relevant Investigations - Please provide date and findings, or attach report:>	

Other Comments:	
<Other Comments:>	

Once completed, please send referral to the Central Referral Service by one of the following methods:
(Please note that for efficiency of processing your referral, our preferred method is Secure Messaging)	
Secure Messaging:	Healthlink address ID: crefserv	
Fax:	1300 365 056	
Post:	Central Referral Service, GPO Box 2566, St Georges Terrace, WA 6831	

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Request for Direct Access Gastrointestinal Endoscopy form last updated: June 2022
Review date: June 2024