OPD Referral Form

Please Note: In order for AJCH to efficiently manage your referral, this form must be fully completed and along with all requested documentation.. All referrals will be dealt with between the hours of 09:00 -14:00 Sun- Thurs.

PLEASE ENSURE ALL THE REQUIRED FIELDS ARE FULLY COMPLETED AND LEGIBLE

Referring Physician Details
Physician Name:*

Contact No:*

Email:*

Hospital/Clinic:*

Requested Specialty
Clinics:

Patient Name:*

Age:*

Gender:*

MaleFemale

Nationality:*

Parent/Guardian:*

Tel No:*

Email:*

Mental Health Form

Step 1

The submitted referrals will be reviewed during working days Sunday to Thursday 9:00 to 14:00. If this was an emergency please advise the patient to visit the nearest emergency department.

Refering physician Details

Physician Name:*

Professional License Number:*

Email:*

Contact No:*


Patient Identification & Demographics

Patient Name:*

Gender:*

BoyGirl

Date of Birth:*

School & Grade:*

Special Education:*

YesNo

Step 2

Parents (Name & Occupation)

Father Name:*

Father Occupation:*

Father's Mobile:*

Mother Name:*

Mother Occupation:*

Mother's Mobile:*


Language(s):*

Patient Siblings (Name & Ages):*

Parental Relationship Status *

MarriedDivorcedSeparated

Step3

Reason For Referral

Please Describe the reason for referral:*

Are the parents/patient aware of the reason for referral?*

YesNo

Please check the most important items:

ADHD symptoms: (e.g difficulties sustaining attention, hyperactivity, impulsivity)Autism Features: (e.g lack of eye contact, lack of emotional reciprocity, repetitive stereotyped behavior, etc)School difficulties: (e.g decline in academic perfomance, learning difficulties)Conduct symptoms (aggresive behavior, truancy, stealing and lying)Oppositional (activity defies and refuses to comply with rules, argues with authority figures)Anxiety symptoms: (e.g. school refusal, phobias/fears, avoidance)OCD symptoms: (e.g. obsession, compulsion)Depressive Symptoms (sadness, irritability, poor sleep/appetite, hopeless, lack of interest/energy)Mania/HypomaniaEating Disorder (Anorexia, Bulimia)Difficulties in adjustment to Medical Illness (including medication on compliance)Psychotic Symptoms (e.g. hallucinations, delusions, etc.)Medication Management (for expert management of patient already on psychotropic medication (e.g. dose adjustment, side effects,etc)Other Symptoms/Concerns

Traumas/Stressors:



Child abuseDomestic ViolenceDeath of a loved oneBullyingParental Discord/Separation

Suicidality (thoughts, plans, attempts): *

YesNo

Self-Harm: *

YesNo

Danger to Others: *

YesNo

Functional impairment due to symptoms:

Social functioning: *

YesNo

Family Functioning: *

YesNo

School Functioning:*

YesNo

When was the onset of the symptoms? *

Was the onset:*

GradualSudden

Any identifiable triggers/stressors? *

Step4

Relevant History

Was the child previously assessed?*

YesNo

Including:

Speech and language AssesmentOccupational AssesmentClinical psychologistEducational assessment (IQ testing)Psychiatry

Others:

Is this referral second opinion?*

YesNo

Previous medical assessments and investigations?


NoneEEGMRIGenetic testing
Hearing Test: YesNo
Vision Test: YesNo

Developmental Delay:*

Speech DelayMotor DelayOther

Did the child lose / Stopped acquiring new skills? (e.g. loss of words) *

YesNo

Medical conditions? *

YesNo

Please specify:

Previous Surgeries? *

YesNo

Please specify:

Allergies? Anything to avoid? *

YesNoDon’t know

Please specify:

Vaccinations up-to-date? *

YesNoDon’t know

List the medications the child is on or has been on previously (including Herbal medications, over the counter

Medication Dose Current?
Yes
Yes
Yes
Yes
Anything you’d like to add?
Comments:


Please attach any previous evaluations to this referral with the patient name clearly marked.

Sleep Clinic Referral Form

Step 1

Patient Detail

Patient Name: *

DOB: *

Sex: *

MaleFemale

Interpreter Needed: *

YesNo, If Yes, Preferred Language:

Parent/guardian Details

Parent/guardian Name: *

Home Phone: *

Mobile Phone: *

Address: *

City: *

Referring Physician Details

Physician Name: *

Clinic/hospital Name: *

Work Phone: *

Contact No: *

Diagnosis: *

Step 2

Health Insurance Details

Insurance Company: *

Insurance Id: *

Please provide a copy of insurance card, front and rear, together with progress notes for authorization purposes *

Step3

Sleep History
Does, Or Has, The Patient:

Snore excessively more than 3 nights a week? YesNo
Been observed to stop breathing or have pauses in breathing during sleep? YesNo
Awaken with gasping, choking, dry mouth or throat? YesNo
Tend to be a mouth breather? YesNo
Occasionally wets the bed (for children 3 and older)? YesNo
Feel sleepy or fatigued during the day? YesNo
Have poor school performance? YesNo
Have hyperactivity or is inattentive? YesNo
Suffers from morning headaches? YesNo
Experience a restless sensation in arms or legs during sleep or in the evening? YesNo
Been told that they make kicking movements during sleep: YesNo
Have difficulty falling asleep at the beginning of the night? YesNo
Have difficulty staying awake during the day? YesNo
Have sudden loss of strength in arms or legs while awake? (Induced by strong emotion) YesNo
Had a previous sleep study? YesNo
If so, when and where? YesNo
How long does it typically take the patient to fall asleep? YesNo
Usual Bedtime:

PM

Usual Wake-up Time:

AM

Step4

Medical History

AsthmaEnlarge tonsilsDeviated septumGastroesophogeal RefluxAllergiesEnlarged adenoidsNasal obstructionCraniofacial MalformationObesityPrevious T&A?Enlarged TongueSeizuresCardiac problemsNasal polypsDiabetesOther Medical History/Allergies:

Medications:

I authorize lab to perform sleep studies on above patient according to their protocols, including urgent initiation of o2 & cpap

Physician:

Date:

OUTPATIENT DIAGNOSTIC IMAGING ORDER

Patient Details

Patient Name: *

Gender:

MaleFemale

Date of Birth: *

Order Date: *

Time: *

Referring Physician:

License No:

Physician Address:

Phone #:

Fax #:

Diagnosis/Reason for Exam:

Signs and Symptoms:

Anaesthesia/Sedation required:

YesNo

Requested Examination is :

With ContrastWithout ContrastWith & W/O ContrastAJCH radiologist to determine

Yes Complete intravascular contrast screening form on page 2 for all contrast examination

General Radiology – No appointment needed – Walk-ins welcome

Requested Examination is :

ChestSkullAbdomenExtremity: Right or Left or Specific region:

Spine: Specify region

Other: Specify region

Ultrasound

RenalHeadTesticularAbdomen

Doppler: Specify region

Other: Specify

Fluoroscopy

Upper GI (Stomach)Upper GI with Small BowelColon (Barium Enema)VCUGOther

*CT Scan – Specific Body Part

CT Scan of

* MRI/MRA Scan – Specific Body Part

MRI Scan of
MRA Scan of

Complete mri order questionnaire on page 3 for all mri studies.

Intravascular Contrast Screening Form

The Department may contact you for additional information to assist in scheduling the exam/s if answering yes to any of the following questions:

Have you ever had Asthma?

YesNo

Are you allergic to any drug or food (especially iodine or seafood)?

YesNo

Have you ever had an injection of contrast media before?

YesNo

Have you ever had a reaction to contrast media before?

YesNo

Are you pregnant or breast-feeding?

YesNo

Are you taking any medications for Diabetes Mellitus especially Metformin?

YesNo

Do you have any of the following conditions: Multiple Myeloma, Liver Failure, Sickle Cell Anaemia, Hepatitis, or Hyperthyroidism?

YesNo

Are you being treated for Kidney disease?

YesNo

Urea:

Date of result:

Creatinine:

Date of result:

Mri Order Questionnaire Form

The Department may contact you for additional information to assist in scheduling the exam/s if answering yes to any of the following questions:

Does the patient have dental hardware? (not including fillings)

YesNo

Does the patient have a ventricular shunt?

YesNo

Does the patient have a programmable CNS shunt?

YesNo

Does the patient have a VNS (Vagal Nerve Stimulator)?

YesNo

Does the patient have cochlear implants?

YesNo

Does the patient have a cardiac pacemaker?

YesNo

Does the patient have any metal inside due to surgery or injury?

YesNo

Does the patient have an artificial heart valve?

YesNo

Does the patient have any electronic devices such as neurostimulators or infusion pumps?

YesNo

Does the patient have a tracheostomy or on a ventilator?

YesNo

Does the patient have an ICD (Internal cardiac defibrillator)?

YesNo

Is this exam part of a research study?

YesNo

Special request/ Comment:

Inpatient Form

Type Of Referral:

UrgentRoutine

Patient Name: *

DOB: *

Nationality: *

Insurance Provider & Details (Including Self Pay)

Insurance Provider:

Details:

Parent Details

Contact No:

Email:

Referring Physician Details

Physician Name:

Contact No:

Email:

Facility:

Referral Information

Indication Of Referral or Diagnosis:

Brief History:

Time/Length Of Complaint:

Investigations Completed:

Current Medication & Treatment:

Critical Care Referral Form

Step 1

Patient Detail

Patient Name: *

DOB: *

Gender:

MaleFemale

Weight/Kg: *

Referring Hospital: *

Referring Unit: *

Unit Phone No.: *

Referring Doctor: *

Mobile: *

Critical Care Service Required: *

Type: *

PICUNICUCICU

Admitting Diagnosis: *

Brief History:

Interventions:

Step 2

Clinical Signs Haematology Time Biochemistry Time
HR:
CRT:
BP:
Resp Rate:
Spo2:
Temp:
AVPU:
GCS:
Glucose:
Urine o/p:
Hb:
WCC:
Plats:
PT:
PTT:
Na:
K:
Urea:
Creat:
Ca:
Known multi-resistant pathogen carrier

ETT Ventilation Blood Gas ARTVENCAP
Size:
Length:
Position:
C-spine:
FiO2:
PIP:
PEEP:
Rate:
pIrI:
PCO2:
PO2:
HCO3:
BE:
Lactate:

Step3

Fluids Drugs
IV Access:
Type of Fluid:
Amount given:
Muscle Relaxant:
Inotropes:
Prostin:
Advice:

For referrals to Al Jalila Children's, kindly fill in the respective form and email it to us. Our Case Management team will get in touch with you soon. Kindly note to attach copies of patient's Emirates ID and insurance to enable us to verify and proceed with a referral.

Form Name
Download File
Sent to

Diagnostic Imaging Department Outpatient Order Form

Browse

Neurodevelopmental

Browse

Electro Neuro Diagnostic Study

Browse

Electro Neuro Diagnostic Study

Patient Details

Patient Name: *

Gender: *

MaleFemale

Date of Birth: *

Order Date: *

Time: *

Contact no:

- Referring Physician – Sign, Stamp, hand over original copy to the Patient for Referral process at AJCH

- Patient – Call for appointment/ walk-in at Registration A for EEG appointment

Referring Physician:

License No:

Physician Address:

Phone #:

Fax #:

Diagnosis/Reason for Referral:

Clinical details/Examination:

Sedation required:

YesNo

Procedures

EEGNCSEMGVEP

Request for EEG

Electroencephalogram (eeg) extended monitoring; 41-60 minutes/ neonatal eeg

Electroencephalogram (eeg) extended monitoring; greater than 1 hour

Electroencephalogram (eeg); including recording awake and drowsy /routine eeg

Electroencephalogram (eeg); including recording awake and asleep /routine eeg

Request for Nerve Conduction Study

One limbTwo limbThree limbFour limb

Repetitive nerve stimulation

Blink reflexes

Sleep Study Referral Form

Step 1

Patient Name: *

DOB: *

Sex: *

MaleFemale

Interpreter Needed: *

YesNo, If Yes, Preferred Language:

Parent/guardian Contact

Parent/guardian Name: *

Home Phone: *

Mobile Phone: *

Address: *

City: *

Referring Physician Contact

Referring Physician Name: *

Clinic/hospital Name: *

Work Phone: *

Mobile: *

Diagnosis: *

Step 2

Health Insurance Information

Insurance Company: *

Insurance Id: *

Please provide a copy of insurance card, front and rear, together with progress notes for authorization purposes

Instruction For Study

Baseline Sleep StudyCPAP/BIPAP TitrationSplit Night StudyOvernight Oximetry

Would you like the patient to be seen at the Paediatric Sleep Clinic prior to the sleep study? YesNo

Step3

Sleep History
Does, Or Has, The Patient:

Snore excessively more than 3 nights a week? YesNo
Been observed to stop breathing or have pauses in breathing during sleep? YesNo
Awaken with gasping, choking, dry mouth or throat? YesNo
Tend to be a mouth breather? YesNo
Occasionally wets the bed (for children 3 and older)? YesNo
Feel sleepy or fatigued during the day? YesNo
Have poor school performance? YesNo
Have hyperactivity or is inattentive? YesNo
Suffers from morning headaches? YesNo
Experience a restless sensation in arms or legs during sleep or in the evening? YesNo
Been told that they make kicking movements during sleep: YesNo
Have difficulty falling asleep at the beginning of the night? YesNo
Have difficulty staying awake during the day? YesNo
Have sudden loss of strength in arms or legs while awake? (Induced by strong emotion) YesNo
Had a previous sleep study? YesNo
If so, when and where? YesNo
How long does it typically take the patient to fall asleep? YesNo
Usual Bedtime:

PM

Usual Wake-up Time:

AM

Step4

Medical History

AsthmaEnlarge tonsilsDeviated septumGastroesophogeal RefluxAllergiesEnlarged adenoidsNasal obstructionCraniofacial MalformationObesityPrevious T&A?Enlarged TongueSeizuresCardiac problemsNasal polypsDiabetesOther Medical History/Allergies:

Medications:

I authorize lab to perform sleep studies on above patient according to their protocols, including urgent initiation of o2 & cpap

Physician:

Date:

      Al Jalila Children's Specialty Hospital

Al Jaddaf - Dubai United Arab Emirates

800 AJCH (8002524)

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