Get the free Upper GI Endoscopy Request form August 2006 - icid salisbury nhs

UPPER GI ENDOSCOPY REQUEST FORM Page 1 of 2 PLEASE PRINT DETAILS Patient Details: Hospital no. Surname NHS no. Forenames Previous surname Date of birth Address Title Sex Home tel. No. Work tel. No.

How to fill out upper gi endoscopy request

How to fill out upper gi endoscopy request:

Obtain the required forms:

Contact the healthcare facility or physician's office where you plan to have the procedure done. Request the upper gi endoscopy request form or any specific paperwork they require for the procedure.

Provide your personal information:

Fill in your full name, address, phone number, and date of birth. This information helps identify you and ensure accurate documentation.

Include your medical history:

Write down any relevant medical conditions, allergies, or past surgeries you have undergone. This information helps the healthcare provider assess any potential risks or complications during the procedure.

Indicate the reason for the upper gi endoscopy:

Describe the symptoms or medical concerns that led you to request this procedure. For example, you may be experiencing chronic abdominal pain, difficulty swallowing, or recurrent heartburn. Be as specific as possible to assist the healthcare provider in evaluating your case.

Specify any medication or supplements you are currently taking:

List all prescription medications, over-the-counter drugs, vitamins, and herbal supplements you use regularly. Include the dosage and frequency. Certain medications may need to be adjusted or temporarily stopped before the procedure, so it is essential to inform the healthcare provider.

Note any relevant family medical history:

If there is a history of gastrointestinal diseases or conditions in your family, provide this information. Family history can be valuable in assessing your risk factors for certain gastrointestinal conditions.

Provide insurance information:

Include your health insurance details, such as the insurance provider, policy number, and any required authorization or referral. This ensures proper billing and prevents any unexpected financial burden.

Who needs upper gi endoscopy request?

Upper gi endoscopy requests may be necessary for individuals who are experiencing certain gastrointestinal symptoms or require diagnostic evaluation. Common conditions that may warrant an upper gi endoscopy include:

Gastroesophageal Reflux Disease (GERD):

Patients who have persistent heartburn, regurgitation, or difficulty swallowing may require an upper gi endoscopy to assess the extent of the condition and identify any complications.

Stomach Ulcers:

Individuals with symptoms such as abdominal pain, nausea, or gastrointestinal bleeding may need an upper gi endoscopy to identify and treat stomach ulcers.

Swallowing Difficulties:

Patients who have trouble swallowing (dysphagia), experience food getting stuck or feel pain while swallowing may require an upper gi endoscopy to evaluate the cause and determine the appropriate management.

Unexplained Anemia:

Individuals with unexplained iron deficiency anemia may need an upper gi endoscopy to investigate possible gastrointestinal bleeding or other underlying causes.

Monitoring and Surveillance:

Patients with a known history of gastrointestinal conditions, such as Barrett's esophagus or gastric polyps, may require regular upper gi endoscopies for monitoring and surveillance purposes.

It is essential to consult with a healthcare professional who can assess your specific symptoms and medical history to determine if an upper gi endoscopy request is appropriate in your case.

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What is upper gi endoscopy request?

Upper GI endoscopy request is a medical procedure where a thin, flexible tube with a camera attached is used to examine the upper gastrointestinal tract, including the esophagus, stomach, and upper small intestine.

Who is required to file upper gi endoscopy request?

Upper GI endoscopy request is typically filed by a gastroenterologist or other healthcare provider who has determined that the procedure is necessary for a patient.

How to fill out upper gi endoscopy request?

To fill out an upper GI endoscopy request, the healthcare provider must provide the patient's information, reason for the procedure, any relevant medical history, and any specific instructions for the endoscopy.

What is the purpose of upper gi endoscopy request?

The purpose of an upper GI endoscopy request is to investigate symptoms such as abdominal pain, heartburn, difficulty swallowing, or gastrointestinal bleeding, and to diagnose conditions such as ulcers, inflammation, or cancer.

What information must be reported on upper gi endoscopy request?

The upper GI endoscopy request must include the patient's name, date of birth, medical history, reason for the procedure, relevant symptoms, any allergies, current medications, and any previous endoscopies.