GENERAL PRACTITIONER REFERRAL (must complete this section)	
PATIENT DETAILS	
Family name:  <PtSurname>	Given Names:  <PtFirstName> <PtMidName>	
Sex:  <PtSex>	Date of Birth:  <PtDoB>	Age:  <PtAge>	
Address:  <PtAddress><PtCity><PtPostcode>	
Phone (H):  <PtPhoneH>	Phone (W):  <PtPhoneWk>	Phone (M): <PtPhoneMob>  	
Email:  <PtEmail>	
Ethnicity :  <PtEthnicity> 
Aboriginal and Torres Strait Islander Status: <PtAboriginal/TorresStraitIslander>
Interpreter Required: <InterpreterRequired?>  (if yes, language spoken): <LanguageSpoken>	
Medicare card no: <PtMCNo>	 	 IRN: <PtMCLine>	 	 Expiry:  <PtMCExpiry>
NOTE: If Medicare ineligible, fees will apply. Contact Triple I for details. 	
DVA Card Number: <PtDVANo> 	 Card Type: <PtDVACard> 
NOTE: If DVA Card Holder, refer to DVA unless Hospital Avoidance category of client.   	
Pension/Health Care Card No:  <PtPension/HealthcareCardNumber>	Private Health Insurer:  <PtInsFund>	
Marital Status:  <PtMaritalSt>	Occupation:  <PtOccupation>	
Next of Kin Details: 
Name:  <NOKName>	 	 	 	 	 	
Relationship to Carer:  <NOKRelation>
Contact Number:  <NOKContact>
Address:  <NOKAddess>	
REFERRING MEDICAL OFFICER’S DETAILS	
Doctor's Name: <RefName>	 	 		
Phone:  <RefPhone>   	Fax: <RefFax>	 	
Address:  <RefAddress>	Email:  <RefEmail>	

 	
  
Clinical Details	
Relevant Medical History: 
<Reactions>
 <PtRelevantMedicalHistory>
Current Medications: 
<CurrentRx>

SPECIALIST BEING REFERRED TO: 	
Please nominate a Specialist: <NominateClinic/Specialist>
*If another specialist has a shorter wait time, the patient could be contacted and offered an earlier appointment. A new referral is not required.	
MEDICAL HISTORY:  	
Weight (kg): <PtWeight(kg)>                      	Height (m): <PtHeight(m)>     	
Previous colonoscopy: <PreviousColonoscopy>	If YES - year of last colonoscopy: <If yes- year:>	
CURRENT SYMPTOMS:		
<Current Symptoms>
<Other Symptoms (please specify)>		
CURRENT MEDICAL HISTORY 	
<Current Medical History (Select All Applicable)>	
Is the patient anaemic or iron deficient? <Is the patient anaemic or iron deficient?>	
Has the patient had a colonoscopy within the last 4 years? <Has the patient had a colonoscopy within the last 4 years?>	
Previous history of difficult colonoscopy (e.g. incomplete colonoscopy, complication)? <Previous history of difficult colonoscopy (e.g. incomplete colonoscopy, complication)?>	
Does patient require a specialist assessment for GI symptoms prior to colonoscopy? <Does patient require a specialist assessment for GI symptoms prior to colonoscopy?>	
Does the patient have capacity to understand instructions of the bowel preparation and advice of the risks and benefits of a colonoscopy? <Does the patient have capacity to understand instructions of the bowel preparation and advice of the risks and benefits of a colonoscopy?>	
Other issues - Please specify: <Other Issues: Please specify>	

For FOBT DAC Referrals please attach the following documents to this referral form
0	Patient Health Summary
0	Positive FOBT result
0	Recent blood tests – FBE, UEC, LFT, Iron studies
0	Specialist Letters for relevant conditions
	
Date:  	Doctor’s signature: