The effect of referral templates on out-patient quality of care in a hospital setting: a cluster randomized controlled trial

Table 1 Referral template for patients referred with dyspepsia

Item no.	Text item
1	Dysphagia
2	Odynophagia
3	Anorexia
4	Weight loss
5	Haematemesis
6	Melaena
7	Vomiting
8	Medications (especially NSAID^a, acetylsalicylic acid, bisphosphonates)
9	Nocturnal symptoms
10	Symptom duration
11	Previous peptic ulcer disease
12	Previous upper gastrointestinal tract operations
13	Jaundice
14	Cervical lymphadenopathy
15	Hepatomegaly
16	Anaemia
17	If <50 years, Helicobacter pylori status

ISSN: 1472-6963