ENDOSCOPY UNIT
ENDOSCOPY UNIT
Queen Mary’s Hospital
Flexible Sigmoidoscopy
If this form does not contain all the required information, it will be returned- please fax to
0208 487 6295
PATIENT DETAILS Date Requested
Surname GP
First Name Pts Address
DOB Pts Tel. No.
ROUTINE / URGENT (please circle)
CLINICAL DETAILS - PLEASE SEE GUIDELINES FOR REFERRAL OVERLEAF
|INDICATIONS |( |Duration / Details |HIGH RISK PATIENTS |
| | | |( |
| | | | |
| | | |Prosthetic heart valve/SBE |
| | | |Pacemaker / ICD |
| | | | |
| | | | |
| | | |Infection risk (Specify) |
| | | | |
| | | | |
| | | |Does this patient require antibiotics? |
| | | | |
| | | | |
| | | |vCJD risk |
| | | | |
| | | | |
| | | |Abnormal Clotting |
| | | | |
| | | | |
| | | |Anticoagulants |
| | | |INR |
| | | | |
| | | | |
| | | |Diabetes: |
| | | |Diet / Oral / Insulin |
| | | | |
| | | | |
| | | |Alcohol: Units/day |
| | | | |
| | | | |
| | | |IMPORTANT INFORMATION |
| | | |* If warfarnised, state |
| | | |plan for stoppage or |
| | | |change |
| | | |* If on Clopidogrel, state |
| | | |instructions for stoppage |
| | | |or continuation |
| | | | |
| | | | |
| | | | |
| | | | |
|Bright red, fresh rectal bleeding: | | | |
| | | | |
|In the absence of diarrhoea, change of bowel | | | |
|habit, weight loss, abdominal pain, iron | | | |
|deficiency anaemia or significant family | | | |
|history | | | |
| | | | |
|Rectal Mass: | |Details: | |
|Peri-anal pain: | |Details: | |
EXAMINATION
ABDO: PR findings:
Requested by ………………………… Signature ……..……………………
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