Date:                
Name:		DOB:		
Address:		
Home Phone:		Mobile:		
	Lives alone	
Insurance		Medicare		Private   Fund:			DVA	

	Patient agrees for colonoscopy by the first available endoscopist	
Referral to a specific endoscopist:	N.B. this may lead to delayed colonoscopy	

Indication for Colonoscopy:	      Positive Faecal Blood Test (please attach reports)
	National Bowel Cancer Screening Program	
Risk of Bowel Cancer
	Personal History of Bowel Cancer     (Please state year of bowel cancer diagnosis & treatment)
	
	Previous colonoscopies    (Attaching all previous colonoscopy and histopathology reports is adequate)
Otherwise please detail dates and findings here

	
	Family History of Bowel Cancer    (Age at diagnosis of bowel cancer of all family members)	

Allergies (please detail)
	
Medications (please include dose of all diabetic medications)

	

Medical History	
	Myocardial infarction*     year:		Stroke    year:	
	Coronary artery stent(s)*     year:		TIA     year:	
	Angina*    Maximal walking distance:		Pulmonary embolism     year:	
	CCF*        Maximal walking distance:		DVT     year:	
	COPD*     Maximal walking distance:	Other		

REFERRING DR:		Signature:		
Provider No:		Tel:		Fax:		

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

ADDITIONAL INFORMATION 
Please include any further relevant clinical information here

Forward referral form to Bowel Screen Program, via Argus (preferred), email: WNSLHD-OrangeDACprogram@health.nsw.gov.au or fax: 63692360