Referral Note
Created by
Grace Wong
Specialty
Family Medicine Specialist
Last edited
10/20/2026
Uses
0 times
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About this template
A reusable referral template for documenting a patient's age, current symptoms, treatments already attempted, and diagnostic workup when communicating with another healthcare provider.
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Age: 52
Symptoms
- Epigastric burning pain and acid regurgitation, worse postprandially and when supine
- 4 months
- Moderate to severe (6/10), waking patient from sleep 2-3 nights per week
- Mild dysphagia to solids and intermittent nocturnal cough; denies hematemesis, melena, or weight loss
Treatment Done So Far
- Pantoprazole (Pantoloc®) 40 mg PO daily for 8 weeks, followed by famotidine (Pepcid®) 20 mg PO QHS and lifestyle modifications (elevating head of bed, avoiding late meals)
- Minimal relief of nocturnal symptoms; persistent breakthrough daytime pyrosis
- Mild intermittent headache with pantoprazole
Workup
- CBC, ferritin, and H. pylori stool antigen test performed on 12/03/2025
- Hb 138 g/L, ferritin 45 ug/L, H. pylori stool antigen negative
- Gastroenterology referral for esophagogastroduodenoscopy (EGD) to rule out erosive esophagitis or Barrett's esophagus
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.