Scarborough Referral Form PATIENT INFORMATION FIRST NAME * LAST NAME * DATE OF BIRTH * ADDRESS * DAYTIME PHONE * EVENING PHONE * HEALTH CARD NO. * GENDER MALE FEMALE PHYSICIAN INFORMATION REFERRING PHYSICIAN ADDRESS PHONE NUMBER PHYSICIAN BILLING NUMBER FAX NUMBER REASON FOR REFERRAL GASTROSCOPY ANEMIA DYSPHAGIA DESPEPSIA REFLUX SYMPTOMS (GRED) NAUSEA WEIGHT LOSS ABDOMINAL PAIN COLONOSCOPY HISTORY OF POLYPS BLOATING/GAS FLATULENCE RECTAL BLEEDING FAMILY HX COLON CA SIGMOIDOSCOPY CONSTIPATION DIARRHEA ANEMIA WEIGHT LOSS ANORECTAL & OTHER HEMORRHOIDS FISSURE -IN ANO FISTULA - IN ANO OTHER SKIN TAGS/LESIONS SEBACEOUS CYST ANUSITIS EXCLUSION CRITERIA - CHECK ALL APPLY - (PATIENTS SHOULD BE REFERRED TO HOSPITAL BASED PHYSICIAN): CARDIOVASCULAR: RECENT MI <6 MONTHS OR UNSTABLEANGINA CHF MORBID OBESITY (BMI) PULMONARY: SEVERE COPD/EMPHYSEMA (ON HOME 02) SEVERE SLEEP APNEA (CPAP) OBSTRUCTIVE JAUNDICE/CHOLANGITIS GI/LIVER BRISK GI BLEEDING/MELENA DECOMPENSATED LIVER DISEASE OTHER: CURRENT PREGNANCY NON-AMBULATORY PATIENT RENAL: DIALYSIS PATIENT SEVERE VALVULAR HEART DISEASE MEDICATIONS: BLOOD THINNERS ASPIRIN PLAVIX WARFARIN/COUMADIN INSULIN OTHER LIST OF ALL MEDICATIONS: MEDICAL HISTORY HX OF ADVERSE REACTION TO SEDATION/ANESTHESIA PATIENT USES PROPHYLACTIC ANTIBIOTICS DIABETES MELLITUS PROSTHETIC HEART VALVE LAST SERUM CREATININE ABNORMAL RENAL FUNCTION ALLERGIES DOCTOR REMARKS: If you are human, leave this field blank. Submit
