This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Main Presenting Complaint: [Text – 98 character maximum]
Reason for Referral: [Text]
World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:
Options:
- Asymptomatic
- Symptomatic but completely ambulatory
- Symptomatic, <50% in bed during the day
- Symptomatic, >50% in bed, but not bedbound
- Bedbound
Priority: Urgent Suspicion of Cancer
Date of Onset: [Date]
Will the patient accept any site for treatment:
- Yes
- No
Symptoms and Investigations
Symptoms
Unexplained weight loss:
- Yes (If Yes, please provide brief details)
- No
Unexplained iron deficiency anemia:
- Yes (If Yes, please provide brief details)
- No
Family history of oesophago-gastric cancer in more than two first degree relatives:
- Yes (If Yes, please provide brief details)
- No
Family history of familial adenomatous polyposis in any first degree relative:
- Yes (If Yes, please provide brief details)
- No
Barrett’s oesophagus:
- Yes (If Yes, please provide brief details)
- No
Pernicious anaemia:
- Yes (If Yes, please provide brief details)
- No
Gastric surgery over 20 years ago:
- Yes (If Yes, please provide brief details)
- No
Known dysplasia, atrophic gastritis, intestinal metaplasia:
- Yes (If Yes, please provide brief details)
- No
Upper abdominal epigastric mass:
- Yes (If Yes, please provide brief details)
- No
Iron deficiency anaemias:
- Yes (If Yes, please provide brief details)
- No
Clincal Examination
Jaundice:
- Yes (If Yes, please provide brief details)
- No
Upper abdominal mass:
- Yes (If Yes, please provide brief details)
- No
Investigations
FBC and ESR sent:
- Yes
- No
LFT, U&E sent:
- Yes
- No
Previous endoscopy done:
- Yes
- No