Direct referrals can be made here for OGDs.
PATIENT NAME (required)
H&C NUMBER (required)
ADDRESS (required)
DATE OF BIRTH (required)
AGE (required)
SEX (required)
MaleFemale
HOME PHONE (required)
WORK PHONE
SYMPTOMS
IndigestionAbdominal painReflux symptomsChange in dyspepsiaVomitingDysphagia/odynophagiaHaematemesis/ melaenaIron deficiency anaemiaWeight loss>3 kgEarly satietyAbnormal Barium meal
REASON FOR REFERRAL (required)
RISK FACTORS
Previous gastric surgeryBarrett’s oesophagusFamily history of upper GI cancerPrevious gastric ulcer
HELICOBACTER STATUS
PositiveNegativeUnknown
HAS HAD HELICOBACTER ERADICATION?
YesNoUnknown
ULCER HEALING DRUGS IN LAST 3 MONTHS?
CO MORBIDITY
Cardio-respiratory diseaseProsthetic heart valveOn anticoagulantsRecent myocardial infarction (6 months)Tablet or diet controlled diabetesInsulin controlled diabetesSevere obesity
REFERRING DOCTOR (required)
MEDICAL PRACTICE (required)
DATE (required)
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