Name: <<Patient Demographics:Full Name>>	 DOB:<<Patient Demographics:DOB (long)>>	
Address:<<Patient Demographics:Full Address>>	
Home Phone: <<Patient Demographics:Phone (Home)>>	Mobile:<<Patient Demographics:Phone (Mobile)>>	
Lives alone:   <<Lives alone?>>

Insurance 
Medicare: <<Patient Demographics:Medicare Number>>          Exp: <<Patient Demographics:Medicare Expiry Date>>
Private Fund: <<Patient Demographics:Health Insurance>>
DVA: <<Patient Demographics:DVA Number>>

Patient agrees to colonoscopy by the first available endoscopist     <<Pt agrees to colonoscopy first available appt?>>

Referral to a specific endoscopist:                                                    N.B. this may lead by delayed colonscopy

Indication for Colonoscopy: 		Positive Faecal Blood Test  (please attach reports)  <<Indication of Colonoscopy + Faecal Blood Test?>>
						National Bowel Cancer Screening Program      <<National Bowel Cancer Screening Program?>>
Risk of Bowel Cancer
<<Please state year of bowel cancer Dx & Tx?>>	Personal History of Bowel Cancer     (Please state year of bowel cancer diagnosis & treatment)
	
<<Details & Dates of previous Colonoscopies?>>	Previous colonoscopies    (Attaching all previous colonoscopy and histopathology reports is adequate)
Otherwise please detail dates and findings here
	
<<Family History of Bowel Cancer?>>	Family History of Bowel Cancer    (Age at diagnosis of bowel cancer of all family members)	

Allergies 
<<Clinical Details:Allergies/Adverse Reactions>>

Medications
<<Clinical Details:Medication List>>

Medical History
<<Myocardial infarction?>>	Myocardial infarction*          Year: <<Year of Myocardial infarction?>>	<<Stroke?>>	Stroke                               Year:<<Year of Stroke?>>	
<<Coronary artery stent(s)>>	Coronary artery stent(s)*       Year:<<Year of Coronary artery stent(s)>>	<<TIA?>>	TIA                                      Year:<<Year of TIA?>>	
<<Angina?>>	Angina*           Maximal walking distance:<<Max walking distance for Angina?>>	<<Pulmonary embolism?>>	Pulmonary embolism          Year:<<Year of pulmonary embolism>>	
<<CCF?>>	CCF*               Maximal walking distance:<<Max walking distance for CCF?>>	<<DVT?>>	DVT                                     Year:<<Year of DVT?>>	
<<COPD?>>	COPD*            Maximal walking distance:<<Max walking distance for COPD?>>		Othe:<<Any other Medical History please note?>>	

Referring Doctor: <<Doctor:Name>>	Signature: 	
Provider Number: <<Doctor:Provider Number>>	Phone: <<Practice:Phone>>	Fax:<<Practice:Fax>>	

Please attach relevant correspondence: - Faecal occult blood test reports
                                                                     - All previous colonoscopy & histopathology reports
                                                                     - Latest UEC
                                                                     - Most recent specialist consultation letter* 	

Forward referral form to RN Jenny Egan, via Argus (preferred), email: jenny.egan@health.nsw. gov.au

ADDITIONAL INFORMATION 
Please include any further relevant clinical information here
<<Any further relevant Clinical information?>>