Referral: <Patient Class>
Also gastroscopy: <Also gastroscopy>
Please attach indication, Rx, H.Pylori, previous tests
…………………………………………………………………………
REFERRAL TO:
Organisation: WBHHS Site: <Site>
Specialist referred to: <Clinician>

REFERRAL FROM:
Referring clinician: <DrName>
Provider No: <DrProviderNo>
Email address: <DrEmail>
Address:<DrAddress>
Phone:	 <DrPhone>		Fax: <DrFax> 
Date:<TodaysDate>
…………………………………………………………………………

PATIENT DETAILS:
Re: <PtFullName>
Surname: <PtSurname>			
Given name: <PtFirstName>
Residential address: <PtAddress>
Postal address: <PtPOAddress>
Home phone:	<PtPhoneH>			
Mobile: <PtPhoneMob>
Sex: <PtSex>					
DOB: <PtDoB>
Patient height:<Patient height>   
Patient weight:<Patient weight>   
Patient BMI: <Patient BMI>
Medicare No:	<PtMCNo>			
Preferred language: <Preferred language>
Interpreter required: <Interpreter Required> 
Aboriginal and /or Torres Strait Islander: <Aboriginal or Torres Strait Islander>
Name of the parent or caregiver: <Name of parent or caregiver>
Social issues relevant to day surgery: <Social issues relevant to day surgery>
…………………………………………………………………………

PRESENTING PROBLEMS:
Colorectal symptoms: <Colorectal Symptoms>
Recent symptoms:<Recent Symptoms>
Rectal bleeding mixed with Stool: <Rectal bleeding mixed with stool>  
Rectal bleeding frank blood: <Rectal bleeding frank blood>
Loss of weight: <Loss of Weight>  		
Amount of weight loss (kg):<Amount of weight loss (kg)>	
Timeframe of weight loss: <Timeframe of weight loss>	
Diarrhoea: <Diarrhoea>				
Duration of diarrhoea : <Duration of diarrhoea>	
Abdominal pain: <Abdominal Pain> 
Describe abdominal pain: <Describe abdominal pain>			
Constipation: <Constipation>		             
Duration of constipation: <Duration of constipation>
Other symptoms: <Other symptoms>		
Describe:<Describe other symptoms>
Fe+ deficiency anaemia: <Fe+ deficiency anaemia> 	(Please attach iron studies)
FOBT result positive: <FOBT result positive>		(Please attach results)
NBCSP test positive: <NBCSP test positive> 		(Please attach NBCSP Dorevitch results)
Examination findings including DRE: <Examination findings including DRE>
Previous Barium Enema: <Previous Barium Enema> 	(Please attach report)
Previous Colonoscopy:  <Previous Colonoscopy>   Date: <Colonoscopy Date> (Please attach report)
Previous Colorectal Cancer: <Previous Colorectal Cancer>	(Please attach D/C summary/report)
Year: <Year>
Previous Polyps: <Previous polyps>		(Please attach report)
…………………………………………………………………………

FAMILY HISTORY:
Family history of Colorectal Cancer: <Family history of Colorectal Cancer>
No. of 1st degree relatives with Colorectal Cancer: <No. of 1st degree relatives with Colorectal Cancer>
Age of 1st degree relatives with Colorectal Cancer: <Age of 1st degree relatives with Colorectal Cancer>
No. of 2nd degree relatives with Colorectal Cancer: <No. of 2nd degree relatives with Colorectal Cancer>
Age of 2nd degree relatives with Colorectal Cancer: <Age of 2nd degree relatives with Colorectal Cancer>

Family history of Polyps: <Family history of Polyps>

Anticoagulant/anti-platelet therapy:  <Anticoagulant/anti-platelet therapy>
Describe anticoagulant/anti-platelet therapy: <Describe anticoagulant/anti-platelet therapy>

…………………………………………………………………………
Full patient health summary: 
<PMHAll>
…………………………………………………………………………
Full current Medication list:
<SelectedRx>
…………………………………………………………………………
Investigations/Results:
<Ix>

Please complete all fields and submit.