Download Direct Access Flexible Sigmoidoscopy: Inclusion criteria and referral

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)
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Infection risk (specify)
-----------------------------------------Does this patient require
antibiotics?
vCJD risk
Abnormal clotting
Diabetes:
Diet
EXCLUSIONS
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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