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Patient Information
Contact numbers: Interpreter required: Language:
Mandatory Information
Past medical history attached? (MANDATORY)List of current medications attached? (MANDATORY)
Relevant Information:
Does this patient have FOBT positive result?
Yes No
Yes No
Yes No
Yes No
Yes
No
Yes No
Yes Yes
Source: From NBCSP Date received result: ___________ From Self-test Kit Date received result: ___________
Date received result: ___________ _________________
(e.g. Rotary Bowelscan)
Reason for self-test: __________________________________________________
Other:
Does the patient have overt rectal bleeding? High risk features? Weight loss
Abdominal massIron deficiency anaemiaPalpable or visible rectal mass
Smoker?
Allergies Nil or Allergy: _____________________Family history First degree relatives with Colorectal Cancer
Age at diagnosis: ____________ Father Mother Brother Sister Children Other: _____________________________
Relevant Blood tests Please attach any recent blood test results, especially: Full Blood Count, Iron studies
Other investigations Please specify:
Previous colonoscopy?
Date: / / If Yes, please attach results of previous colonoscopies.
Referring Doctor – Practice stamp or details Doctor’s Signature:
Date:
Please tick the appropriate FOBT clinic Westmead FOBT clinic: please email this form to [email protected] or fax to: (02) 8890 5118 Please call 0439 702 568 if you have any questions Blacktown FOBT clinic: please email this form to [email protected] or fax to: (02) 9881 8208 Please call 0439 950 528 if you have any questions
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Facility:
RAPID ACCESS FAECAL OCCULT BLOOD TEST
CLINIC REFERRAL
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COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
FAMILY NAME MRN
GIVEN NAME MALE FEMALE
D.O.B. _______ / _______ / ________ M.O.
ADDRESS
LOCATION / WARD
Y e s No Y e s No Y e s No Y e s No
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