JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Colorectal Unit
Sign in to Google
to save your progress.
Learn more
Referring Doctor
Your answer
Referral Date
MM
/
DD
/
YYYY
Referring Doctor’s contact details
Your answer
Referring doctors email address
Your answer
First Name
Your answer
Surname
Your answer
Date of Birth
MM
/
DD
/
YYYY
Contact Number
Your answer
Email Address
Your answer
Reason for Colonoscopy
Colorectal cancer screening
Rectal Bleeding
Follow Up
Anaemia
Abdominal Pain
Change in Bowel Habit
Other:
Clear selection
Current medication
Yes
No
Aspirin
Warfarin
NSAIDS
Iron therapy
Yes
No
Aspirin
Warfarin
NSAIDS
Iron therapy
Clear selection
Other
Your answer
If the patient is on Aspirin can this be safely stopped?
Yes
No
Clear selection
Heart Disease
No
Other:
Clear selection
Kidney Disease
No
Other:
Clear selection
Pulmonary Disease
No
Other:
Clear selection
Allergies
No
Other:
Clear selection
History of anaesthetic problems
No
Other:
Clear selection
History of anaesthetic problems
No
Other:
Clear selection
Family history of anaesthetic problems
No
Other:
Clear selection
Porphyria
No
Other:
Clear selection
Diabetes or Thyroid problems
No
Other:
Clear selection
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
