Colonoscopy and/or Gastroscopy direct access referral form
Patient details	Referral information	
Patient name : <<Patient Demographics:Full Name>>

Medicare number : <<Patient Demographics:Medicare Number>>

Address: 
<<Patient Demographics:Full Address>>

Phone (M/H): <<Patient Demographics:Phone (Mobile)>>/<<Patient Demographics:Phone (Home)>>

Date of birth: <<Patient Demographics:DOB>>	
Age: <<Patient Demographics:Age>>

Nex t of kin: <<Patient Demographics:Next of Kin>>

Nex t of kin phone number: <<Patient Demographics:Next of Kin Phone>>

Gender	

	
Male  	

	
Female  	

	
Non-binary	

	

Privately insured	

	Date of referral: <<Miscellaneous:Date>>

Referring practice :

Referring doctor (print): 
<<Doctor:Full Details>>

Email: <<Addressee:E-mail>>

Phone/pager:<<Addressee:Phone>>

Signature :

Referred to:
<<Addressee:Full Details>>	

Interpreter required?		

	Yes  		

	No  	Language (specify)		

	Colonoscopy		

	Flexible-sigmoidoscopy	

Does this patient also require  a gastroscopy?		

	Yes		

	No	Reason 		

Smoking		

	Yes		

	No	Alcohol    Units per week		BMI 		

Provisional diagnosis:

Indication A: Symptoms and investigations* (circle main indication, tick all others and provide a copy of results)                                                 	

	Positive iFOBT		

	NBCSP 		

	Abnormal imaging		

	Anaemia: (provide results below)* 		

	Hb		

	Rectal bleeding, duration		months		

	MCV		

	Change in usual bowel habit, duration		months 		

	Ferritin 		

	Diarrhoea (stool culture negative), duration		months		

	Calprotectin 		

	Unexplained abdominal pain > than 6 weeks 		

	CRP		

	Unexplained weight loss		

	Coeliac serology 		

	Palpable mass		

	Abdominal		

	Rectal		

	Others		

Active and significant co-morbidities

Colonoscopy referral information
Clinical notes:

Indication B: Surveillance
(refer to NHMRC guidelines)	Date of last colonoscopy
(Provide a copy of results)	/	/	

	Adenoma surveillance group:		

	A		

	B		

	C		

	D	

	IBD surveillance group:		

	1		

	2		

	3	Date of IBD diagnosis: 	/	/ 	
	Date of primary sclerosing cholangitis diagnosis: 	/	/	

	Family history risk category:		

	1		

	2		

	3	Syndrome 		

	Colorectal cancer	Date of diagnosis		/		/	

Clinical notes:

 Allergies and Medicines	

Current medicines:
<<Clinical Details:Medication List>>
	
Allergies/Adverse reactions:
<<Clinical Details:Allergies/Adverse Reactions>>	

 Past medical history/active co-morbidities	

Is the patient ambulant and independent?		

	Yes		

	No	

Is an overnight stay required ?		

	Yes		

	No	

Past medical history:
<<Clinical Details:History List>>