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Direct Access Flexible Sigmoidoscopy: Inclusion criteria and referral form Section 1 Patient information (in BLOCK CAPITALS) Surname: Date of referral: First Name: Mr Miss Mrs Ms Date of birth: NHS No: Other: Address: Post code: Enema prescribed Yes Home Telephone: Mobile: Transport: No Interpreter: No Language: Ethnicity: Suitable for self administration Yes Not suitable for self administration No Patient Information Pack given to patient Section 2 Practice Information (please use practice stamp if available) Referring GP: Locum: No Practice address: Telephone: Fax: Practice Code: Section 3 Clinical Information (please tick where applicable) Medical history (including infections): Medications: INDICATIONS (please tick where applicable) Patient 50+ LGI 1. Rectal bleeding with or without anal symptoms and no change in bowel habit for 6 weeks or more LGI 2. Rectal bleeding with change in bowel habit (increased frequency/increased looseness) for 6 weeks or more LGI 3. Change in bowel habit for 6 weeks or more (increased frequency/increased looseness) without rectal bleeding HIGH RISK PATIENTS (please tick where applicable) Infection risk (specify) -----------------------------------------Does this patient require antibiotics? vCJD risk Abnormal clotting Diabetes: Diet EXCLUSIONS Croydon University Hospital Patients with constipation Unexplained iron deficiency anaemia Palpable rectal mass/Lower abdominal mass Patients who have significant co-morbidities (respiratory, cardiac, renal or neurological) Patients who have had an endoscopic investigation within the last two years Patients who are taking anti-coagulants for prosthetic heart valve and coronary stents Patients without the mental capacity to consent Patients who are already under investigation for suspected cancer Patients with existing inflammatory bowel disease Patients with known infective diarrhoea Patients who will require an overnight stay Fax number: 020 8401 3855