NHS e-Referral Service
Endoscopy request form
ALARM SYMPTOMS: Patient with any of these symptoms should be referred into appropriate 2WW service
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Dysphagia
Epigastric mass
Recent onset dyspepsia, aged >55 yrs
Unintentional weight loss
Persistent vomiting
Iron deficiency anaemia with no obvious cause
Obstructive jaundice
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PR bleeding persistently, without loose stools and without anal
symptoms, aged >50 yrs
PR bleeding & loose / more frequent stools for > 6 wks
Loose/more frequent stools > 6 weeks, aged > 50 yrs
Right sided mass
Rectal mass
SECTION 1: PATIENT DEMOGRAPHIC DETAILS
Patient NHS number:
UBRN:
Patient first name:
Patient last name:
Date of Birth (DD/MM/YY):
Gender:
Male
Female
st
Patient address (1 line):
Patient town / city:
Patient postcode:
Patient contact number:
Patient contact number 2:
SECTION 2: REFERRER INFORMATION
First name:
Last name:
Referrer role:
GP
Other
GP Practice Code:
Referrer contact no:
GMC registration number:
Referrer e-mail address:
INDICATIONS FOR AN ENDOSCOPY:
Gastroscopy
Flexible Sigmoidoscopy
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Change in bowel habit, no rectal bleeding, aged < 50 yrs
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Painless rectal bleeding, aged < 50 yrs
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Peri-anal symptoms, any age
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Recent onset of reflux symptoms that fails to respond to
PPI and/or gastro prokinetic therapy
Positive helicobacter test & dyspepsia that fails to respond
to eradication therapy
Dyspepsia and concurrent use of NSAIDs
For duodenal biopsy – indications are iron deficiency
anaemia, diarrhoea, unexplained weight loss and positive
coeliac serology. Consider 2WW for alarm symptoms.
SECTION 3: INVESTIGATION REQUEST DETAILS
Current Request
Gastroscopy (Upper GI)
Please complete Section 4 and 5
Flexi Sigmoidoscopy (Lower GI)
Please complete Section 4
Colonic Imaging Advice (CIA)
Please complete Section 4 and 5
Patient had previous endoscopy?
Yes
If yes, what type of previous endoscopy?
Gastroscopy
UBRN:
Reason for request:
Relevant clinical history:
No
Date (DD/MM/YYYY):
Flexi Sigmoidoscopy
Colonoscopy
SECTION 4: MEDICAL INFORMATION (all requests)
Is the patient fit for a day case procedure?
Yes
If unsure refer patient to relevant outpatient clinic and
not for direct access
Note: If the patient requires sedation, they must be able to organise an escort home and have observation overnight
Does the patient have capacity to give informed consent?
Is this patient diabetic?
Yes
No
Yes
No
If yes, is the patient insulin dependent?
Yes
No
Has the patient had poorly controlled angina / MI in last 3 months?
Yes
No
Has the patient had prosthetic valve replacement?
Yes
No
Has the patient previously had subacute bacterial endocarditis?
Yes
No
Has the patient had a vascular graft within the last year?
Yes
No
Does the patient have COPD / poorly controlled asthma?
Yes
No
Is the patient on Warfarin?
Yes
No
Duration:
Yes
No
Which Drug?
Is the patient on aspirin, clopidogrel, or any other anti-platelet drug?
Duration:
If you have answered ‘yes’ to any of the questions above, please ensure that you include any additional relevant clinical information
above.
SECTION 5: GASTROSCOPY AND CIA ONLY
H Pylori status:
Positive
Negative
Not known
NSAID:
Yes
No
Duration (weeks):
Must continue:
PPI/H2 antagonist:
Yes
No
Duration (weeks):
Patient responded
Yes
Yes
No
No