Orange Health Region Referral for Positive FOBT for National Bowel Cancer Screening Program (MBCSP)

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:                                          Date: <<Miscellaneous:Date (short)>>
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)  wnswlhd-bowelscreenpro@health.nsw.gov.au  or  Fax (02 )6369 2305

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