GP Referral Form
Direct Access Endoscopy
Dubbo Health Service
Ph: 6809 7711		

Referral for:	  <Does patient require a Colonoscopy?>  Colonoscopy	  <Does patient require Gastroscopy?>  Gastroscopy 	(please select one or both)	

Name:	    <PtName>	D.O.B:	   <PtDoB>	Sex:  <PtSex>	
Address:	   <PtAddress>	
Telephone:	(H)   <PtPhoneH>	(W)   <PtPhoneWk> (M)  <PtPhoneMob>	
Medicare	   <PtMCNo>	Private Fund: <PtHealthIns>        	
Email Address:	<PtEmail>	Lives Alone: <Does patient lives alone?>	
DVA Gold Card holder:	   <PtDVANo>	Aboriginal or Torres Strait Islander:	   <PtEthnicity>	

Lower GI Indications for Endoscopy: - (Please mark with an X which are relevant to the patient)	
	Abnormal imaging (lower GI- attach report)		Change in bowel habits (Specify Below) 	
	Chronic diarrhoea		Faecal mucus	
	Lower abdominal pain		Pain on defaecation	
	Positive FOBT – Performed by NBCSP		PR bleeding > 4 weeks	
	Positive FOBT – Performed by GP		PR bleeding < 4 weeks	
	Sensation of incomplete evacuation		Surveillance (Specify Reason and Attach Reports)	
	Suspected inflammatory bowel disease		Bloody diarrhoea with –ve stool MCS (Attach results) 	
	Unexplained iron deficiency (Please provide Hb & Ferritin Results) 		Other (e.g. Palable Mass, Diverticulitis – Specify Below) 	
Surveillance Reason: (if relevant) – Attach Reports     (Please mark with an X which are relevant to the patient)	
	Colorectal cancer		Family history colorectal cancer	
	Inflammatory bowel disease		Polyps	
Upper GI Indications for Endoscopy:  (Please mark with an X which are relevant to the patient)	
	Abnormal imaging (Upper GI – Attach Report)		Dysphagia	
	Dyspepsia		Haematemesis / Melaena	
	 Persistent nausea and vomiting		Positive coeliac serology (Attach report)	
	Reflux		Surveillance (Barrett’s)	
	Upper abdominal pain		Unexplained iron deficiency (please provide Hb & Ferritin Results) 	
	Other (e.g. Bloating, Weight Loss, Palpable Mass) 			

Height: <Patient height?> cm
	  Weight: <Patient weight?> kg 	
Medical History (Please mark with an X which are relevant to the patient)	
	Bleeding disorder		Kidney disease	
	Neurological history		Obstructive sleep apnoea	
	Recent surgery		Significant lung / airway disease	
	Liver disease		Diabetes
Insulin dependent      or      Non-insulin dependent     	
	Heart disease
       - Implanted defibrillator in situ 
       - Pacemaker in sit
       - Coronary stents in situ (specify when)
                < 1 year     or     > 1 Year			
	None of the above 			
Additional Medical History Details:
<PMHActive>
	
Special Considerations:(Please mark with an X which are relevant to the patient)	
	Significant alcohol history		Significant illicit drug history	
	Significant mental health issues		None of the above	

Is the patient taking any anti-coagulant or anti-platelet medication/s, including Aspirin?
       Yes     or      No  
If yes, please specify drug and reason:
Other Medications 
<SelectedRx>

Allergies / Reactions (Inc. latex, tapes etc)
<Reactions>

Relevant Investigations – Please provide date and findings, or attach report:	
Referring Doctors Details 
Doctors Name: <DrName>
Doctors Provider Number: <DrProviderNo>
Practice Name: <Practice>
Practice Address: <UsrAddress>
Practice Phone: <UsrPhone>

Doctors Signature:  					                   Date:  <Date>
Please attach relevant correspondence:   
                             - Faecal occult blood test reports
                             - All previous colonoscopy & histopathology reports
                             - Latest UEC
                             - Any relevant letters from other Specialist	
Forward referral form to Frances O’Brien (DAC Co-ordinator), via Argus WNSWLHD-ccdubpreadmiss@health.nsw.gov.au

ARGUS summary
Patient Name:<PtSurname>, <PtFirstName> DOB:<PtDoB>
Recipient: <AdrName> Date of Report: <Date>