GP Assessment Report

Referred / not referred for colonoscopy
 following a positive FOBT result 		

Instructions for using this report
	1.	Mandatory fields are marked with as asterisk (*).
	2.	In section 3, the mandatory fields only apply to the segment checked..
	3.	Preferred fields are marked with a plus (+).	Fax to
1800 115 062	

 1 Patient Details			Participant ID number 			<Participant ID No (from results letter)>
		(Located on their results letter)	
	* Medicare/DVA number	 <PtMCNo>  <PtDVANo>	
	* Family Name	  <PtSurname>	
	* Given name(s)	  <PtFirstName>	
	* Date of Birth	  <PtDoB>	* Gender  <PtSex>	
	+ Contact telephone n.o.	 (h) <PtPhoneH>  (m) <PtPhoneMob>	

 2 Symptoms present at time of assessment following a positive FOBT result  	
 (mark all that apply)	
No Symptoms  		Recent onset rectal bleeding ( ≤ 6 months)  		
				
Longer standing rectal bleeding (> 6 months)  		Significant change in bowel habits  		
				
Iron deficiency anaemia  		Abdominal Pain  		

3  Assessment outcome following a positive FOBT result 
Referred for colonoscopy  		 * Specialist, hospital/clinic name and location	
		  <AdrDetails>
 Contact Phone:<AdrPhone>	

Not Referred for colonoscopy  		 * Reason for not referring for colonoscopy	
Bowel cancer previously diagnosed  		Patient declines colonoscopy  		
				
Limited life expectancy  		Significant comorbidity  		
				
Recent colonoscopy (< 18 months)  		Other medical condition(s)  		

4 * Was the patient referred for other examination(s)?
No 		Yes 		  Indicate which examinations	
Double Contrast barium enema  		Sigmoidoscopy  		CT colonography  		
						
Other  		Please specify below				

5 Provider details

* Provider number for payment   <DrProviderNo>	* Date of consultation  <TodaysDate>	
		
 Name  <DrName>		

Note: When referring your patient for colonoscopy, please indicate that they are a Program participant to assist with reporting to the Program Register. If preferred, Program stickers can be obtained by calling the Information Line on 1800 118 868.	

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