This form should be submitted via the Referral Support Service
Reference/Priority
Referral Date:
Referral Date	

	Priority:
Referral Urgency	

	NHS Number:
NHS Number	

Patient Details
Title:
Title	

	Forename(s):
Given Name	

	Surname:
Surname	

Date of Birth:
Date of Birth	

	Gender:
Gender	

	Ethnicity:
Ethnic Origin	

Contact Details
Address Line 1:
Home Address House Name/Flat Number	

	Address Line 2
Home Address Number and Street	

	Address Line 3:
Home Address Village	

Town:
Home Address Town	

	County:
Home Address County	

	Postcode:
Home Address Postcode	

Phone:
Patient Home Telephone	

	Mobile:
Patient Mobile Telephone	

	Text Message Consent:

	
Email:
Patient E-mail Address 	

Referrer/Practice Details
Referring Name:
Referring User	

	Referrer Code:
Free Text Prompt 	

	Practice Code:
Organisation National Practice Code	

Clinic Details
Specialty:
Diagnostic Endoscopy 	

	Clinic Type:
Gastroscopy 	

	Named Clinician:
     	

Patient Choice Preferences
Provider 1:
Referral Target Service Name 	

	Provider 2:
     	

Preferences
Vulnerable Patient:

	Vulnerable Reason:
     	

	Confidential/Silent Referral:

	
Preferred Contact Time:
     	

	Interpreter Required:

	Preferred Language:
Main Language 	

Referral Details
Non-clinical information for the booking team:
     	

Referral Reason/Letter Text:
     	

Referral Criteria
This form is not to be used for patients with dyspepsia and Red Flag symptoms.
For these patients use the 2WW referral form for:
•	Patients of any age with dysphagia
OR
•	Patients aged 55 years and older
•	WITH (unintentional and unexplained) WEIGHT LOSS
•	AND ANY of the following
o	Upper abdominal pain
o	Reflux
o	Dyspepsia
•	An upper abdominal mass	
This form is for these groups of patients:
•	Treatment-resistant dyspepsia (refractory or recurrent symptoms despite optimal medical management and lifestyle changes)
•	NICE recommend clinicians consider, non-urgent upper gastrointestinal endoscopy, (to assess for upper GI cancer in people aged 55 or over) with:
•	Upper abdominal pain with low haemoglobin levels
•	Raised platelet count with any of the following: Nausea, Vomiting, Weight loss, Reflux, Dyspepsia, Upper abdominal pain
•	Nausea or vomiting with any of the following: Weight loss, Reflux, Dyspepsia, Upper abdominal pain
•	Patients with a history of unexplained worsening of dyspepsia AND a history of
o	Barrett’s oesophagus
o	Previous biopsies with dysplasia
o	Pernicious anaemia
o	Peptic ulcer surgery
o	Family history of Upper GI cancer
•	New patients to the area with known Barrett’s that require surveillance endoscopies

Please refer to local guidance on the Management of Dyspepsia in Primary Care before requesting an endoscopy. This helps demonstrate your referral is in line with NICE guidance and is clinically justified.

Referrals are not triaged by gastroenterologists Open Access Endoscopy is a nurse led service that aims to see patients with six weeks of referral. Patients will be followed up at the discretion of the endoscopist depending on findings. Referring clinicians have a shared responsible for ensuring they receive and act on biopsy results which may not be available for several weeks after the endoscopy.	
Why do you think your patient should have a gastroscopy? (these are based on NICE criteria)

	Treatment-resistant dyspepsia (refractory or recurrent symptoms despite optimal medical management and lifestyle changes)	

	Upper abdominal pain with low haemoglobin levels	

	Raised platelet count with any of the following:
 Nausea
 Vomiting	

	Raised platelet count or Nausea or vomiting with any of the following
(see red box above and consider 2WW form if 55 years or over)
 Weight Loss
 Reflux
 Dyspepsia
 Upper abdominal pain	

	Patients with a history of unexplained worsening of dyspepsia AND a history of
 Barrett’s oesophagus 
 previous biopsies with dysplasia
 pernicious anaemia
 peptic ulcer surgery
 family history of Upper GI cancer	

	New patient to the area with known Barrett’s that requires surveillance endoscopies (please attach previous endoscopy reports available) For these patients only ignore rest of the form 	

When did your patient first present with symptoms?

Because lifestyle changes are important in treating dyspepsia and because they take time, an endoscopy should not normally be requested < 2 months after presentation unless patients have recurrent symptoms after one month’s full dose PPI treatment and do not have any lifestyle changes to implement.	 > 2 months

 < 2 months, and they have no lifestyle changes to implement	
I confirm my patient has had one month of full dose PPI treatment (demonstrates following NICE guidance)	 Yes
	
Were they on any medication that has been stopped that might have been contributing to their symptoms?	 Yes  No
Please detail:      	
Are they on any medication that cannot be readily stopped that might be contributing to their symptoms?	 Yes  No
Please detail:      	
Has your patient had H. pylori stool antigen testing either before PPI treatment or at least 2 weeks after PPIs have been stopped?	 Yes  No (detail below)
     	
What was the H. pylori test result?	 Positive  Negative (skip next question)	
Has your patient had triple therapy in the last 6 months?	 Yes  No	
To help identify local patterns of H. pylori resistance please detail which treatment they had	
Detail which treatment they had and at what dose? Approximate date this was taken?      	
1st Antibiotic:  	Other: please detail:      	
2nd Antibiotic: 	Other: please detail:      	
PPI:                   	Other: please detail:      	

What is your patient’s BMI?	Single Code Entry: Body mass index  	
Is your patient a current smoker?	Single Code Entry: Tobacco consumption  	
How many units of alcohol does your patient drink per week?	Single Code Entry: Alcohol consumption  	
Gastroscopy is not a pleasant investigation. It costs around £400 and it carries some risks. Please confirm that you have given your patient ALL the NICE recommended advice below. Audit of these answers will help the NHS understand to what extent GPs feel their lifestyle choices are leading to gastroscopies	
•	Losing weight, where BMI > 25, may improve their symptoms
•	Minimising their alcohol intake may improve their symptoms
•	Stopping smoking may improve their symptoms
•	Diet advice
o	Avoiding trigger foods such as coffee, chocolate, tomatoes, fatty or spicy foods
o	Eating smaller meals and
o	Eating evening meals 3-4 hours before going to bed, can help improve their symptoms
•	Addressing causes of stress, anxiety and depression which may worsen symptoms.	Yes, I have given them all of this advice (where it applies) AND I feel my patient

 has few or no lifestyle changes my patient can implement to minimise their symptoms

 is engaging with lifestyle changes to minimise their symptoms

 could benefit from more support to engage with lifestyle changes to minimise their symptoms	
Please confirm your patient is aware of the need to stop acid suppression therapy (PPIs or H2 antagonists) for at least two weeks before the procedure date, and self-treat with antacid and/or alginate therapy if needed.	 Confirmed (please untick if not true)	
Has your patient had previous gastric surgery?
If yes, please detail:      	 No previous gastric surgery (please untick if not true)	
This section must be completed Please tell us if they have ANY OF THE FOLLOWING: Diabetes, Cardiac or Respiratory disease, Cognitive impairment, Frailty, Anticoagulation or other relevant history:      
Requests will be returned if this section is not completed or detail of significant medical problems are not provided here. Managing such patients takes additional staffing that delays lists if not planned for. If your patient has any of these then consider obtaining the advice of gastroenterologists before requesting an open access endoscopy.

Please confirm that your patient does NOT have any of the above problems that could affect their ability to safely tolerate a gastroscopy.  Confirmed, they do not.	
Please ensure your patient is aware of the need to stop acid suppression therapy (PPIs or H2 antagonists) for at least two weeks before the procedure date, and self-treat with antacid and/or alginate therapy if needed.	
Please confirm the following tests have been checked (since symptoms developed)
	Tested?	Result	Details	
Hb	 Yes
Mandatory	 Normal
 Abnormal, consider 2WW	Single Code Entry: Haemoglobin estimation  	
Platelets	 Yes
Mandatory	 Normal
 Abnormal consider 2WW	Single Code Entry: Platelet count  	
If your patient had any other investigations to rule out differential diagnoses, please tick any they’ve had recently and in the free text box below detail any relevant findings

 Upper GI Ultrasound
 ECG

Results of above where done:      	

A report and brief advice will be provided, and follow-up arranged if clinically indicated

Patient may be asked to enter a research trial – tick box if this may be inappropriate 
(The patient will be asked to give informed consent)

Active Problems
Problems
Allergies
Medication
Medication