SECTION 1: PATIENT DEMOGRAPHIC DETAILS
Patient NHS number: / UBRN:
Patient first names: / Patient last name:
Date of Birth (DD/MM/YY): / Gender: / Male Female
Patient address (1st line):
Patient town / city: / Patient postcode:
Patient contact number: / Patient contact number 2:
SECTION 2: REFERRER INFORMATION
First name: / Last name:
Referrer role: / GP On behalf of GP
GP Practice Code: / Referrer contact no:
GMC Registration No: / Referrer e-mail address:
SECTION 3: TEST SERVICE REQUEST (refer to 18 wk indigestion pathway)
Priority: / Routine Urgent
Does the patient have an infection or do they pose an infection risk to others? / No Yes
Test requested:
Urea Breath Test / General Contraindications: (Medication Cessation Periods)
Pre Eradication Post Eradication / Antibiotics: stop taking 28 days before Test / PPI: stop taking 14 days before test
If post eradication, details of eradication regime and date:
N.B: Minimum requirement of 6 wks between eradication and Urea Breath Test / H2 antagonists: stop taking 48 hours before test / Antacids / Imodium / gastric motility: stop taking 48 hours before test
Reason for Request:
Relevant clinical history:(include detail and dates of any previous related investigations e.g. endoscopy)
SECTION 4: COMPLETE FOR ALL REQUESTS
Is the patient on any medication? / No Yes
If yes, enter full details : Gastric Medication Other Medication
Does the patient have asthma? / No Yes
Does the patient have diabetes? / No Yes
Does the patient have chronic obstructive pulmonary Disease? / No Yes
If you have answered ‘yes’ to any of the questions above, please ensure that you include any relevant information in the clinical history section