Screening-RelatedColonoscopyReferral

Medicine HatRegionalHospital

Fax: 403-528-5644 Phone: 403-529-8016

  • Referralswillbetriagedandassignedaprioritybasedontheinformationincludedinthisform.Highestpriority willbegiventothosewithanabnormalFecalImmunochemicalTest(FIT).
  • Incompletereferrals,referralsforpatientsthatdonotmeetcurrentscreeningguidelines,andreferralsthatdo notmeeteligibilitycriteriawillnotbeacceptedandwillbereturnedtothereferringphysician.
  • Mandatory Sections*: Eligibility Criteria, Patient Health History, and Body Mass Index. Please ensure these sections are complete prior to submitting referral form.

ReferringPhysicianName / Fax / Signature / Date(yyyy-Mon-dd)
PRACID# / AffiliatedPCN
EligibilityCriteria*
  • Age74yearsoryoungerwithvalidAHCIPcoverage
  • Asymptomatic.NoGIsignsorsymptomsrequiringspecialistconsultation(i.e.rectalbleeding,anemia)
  • Thepatientisclinicallystableandabletoundergoconscioussedation
  • Thepatienthasaneligiblereasonforreferral-checkonebelow
Positivefecaloccultbloodtest(FITorguaiac)performedinanasymptomaticindividualforcolon cancerscreening.Mustbeage50-74;patientsoutsideagerangewillbereviewedonacaseby casebasis(appendresults)
Personalhistoryofcolorectalcancer(CRC)oradenomatouspolyps(appendresults)
FamilyhistoryofCRC or †high risk adenomotous polyps in one or more first degree relatives
►1stdegreerelativediagnosedwithCRC or †high risk adenomatous polyps:
Younger thanage60 Older than age 60 Unsure of age
PolyponsigmoidoscopyorsuspectedpolyponCTcolonographyorbariumenema(appendresults)
Other(specify)
PatientHealthHistory* Body Mass Index:*
Does this patient have any significant comorbidities as listed on page 2:
Yes No (If yes, please complete page 2)
►Please attach current medication and/or allergy list
►Please ensure most recent bloodwork (CBCs) is completed with referral form

AdditionalRequirements(i.e.wheelchairbound,limitedmobility,etc)

SpecifyInterpreterneeded►Specifyprimary

language

†Note: 1) High risk adenomotous polyps include: 3-10 adenomas, one adenoma >/= 10mm, any adenoma with villous features, highgrade dysplasia or

intramucosal carcinoma.

2) Patients with one second or one third degree relative with CRC or a high risk adenomotous polyp are considered average risk.

Screening-RelatedColonoscopyReferral

Medicine HatRegionalHospital

Fax: 403-528-5644 Phone: 403-529-8016

Previous colonoscopy
Yes No ► Approximate Date (yyyy-Mon-dd) (Append a copy of colonoscopy/pathology reports)

CardiacHistory

Acutecoronarysyndrome(mustbegreaterthan12months)

Angina(mustbeasymptomaticinpast6months)

Atrialfibrillation

Arrhythmia

CABG and/orcoronaryangioplastyand/orstent(mustbegreaterthan6monthspost)

Cerebrovascularevent(mustbegreaterthan12monthsandnosignificantdeficits)

Pacemaker(mustbegreaterthan3months)

Antithrombotics ► Specify type Also taking Aspirin

RespiratoryHistory

AsthmaorCOPD.Mildtomoderate-wellcontrolledoninhalersand/orlowdosesteroids

SleepApneawithorwithoutCPAP(Note:notallfacilitiesacceptpatientswithBMIgreaterthan35andonCPAP)

MedicalHistory

DiabetesMellitus

Onoralhypoglycemicsand/orinsulin (referring physician to manage dosing for colonoscopy)

Kidneydisease(glomerularfiltrationrate(GFR) mustbegreaterthan45orcreatininelessthan150)

Chronicviralhepatitis(withoutadvancedcirrhosis)

Humanimmunodeficiencyvirus(HIV)

Coagulopathy(vonWillebrand,hemophilia)

Seizuredisorder-wellcontrolled(noorlittleseizureactivitywithin6months)

Anatomicalorstructuralabnormalitiesofneckorface

Anyothermedicalproblempotentiallylimitingthesafety ofthescopeand/orsafety ofthebowel

preparation. Pleasespecify

SurgicalHistory

Surgerywithin1year,specify