Download Colorectal Cancer Surgical Database Preoperative Co

Colorectal Cancer Surgical Database
Preoperative Co-Morbidities Form
Patient Given Name: _____________________ Surname: ______________________________
Patient UR Number: _____________________
Co-Morbidities
Height (cm s): ____________
Weight (kgs): _____________
Hi story of Smoking:
□Yes □ No
└> if Yes, Current Smoker: □Yes
□ No
Bowel
Inflammatory Bowel Disease:
□Yes □ No
└>
If Yes,
Type:
□
□
□
Ulcerative colitis
Crohn’s disease
Indeterminate colitis
Vascular
Known Vasculopathy:
□Yes
□ No
└> If Yes,
□Yes
Hypertension:
Peripheral Vascular Disease:
□ No
Heart
Ischaemic Heart Disease:
□Yes □ No
└> If Yes:
Previous stent or intervention:
Myocardial Infarction:
□Yes □ No
□Yes □ No
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□Yes □ No
Colorectal Cancer Surgical Database
Preoperative Co-Morbidities Form
└> If Yes, time period bet ween last documented myocardial
infarction and surgery:
□
□
□
□
□
Angina:
Less than or equal to 6 hours
Greater than 6 hours but less than 24 hours
1 to 7 days
8 to 21 days
Greater than 21 days
□Yes □ No
└> If Yes, CSS Classification:
Angina type:
Arrhythmia:
□0 □1 □2 □3 □Not available
□ Stable □ Unstable
□Yes □ No
└> If Yes, Arrhythmia type:
□Atrial fibrillation or flutter requiring treatment
□ Heart block
□ Sustained ventricular tachycardia or ventricular fibrillation
□ Other arrhythmia (sick sinus syndrome)
Hi story of Conge stive Heart Failure:
□Yes □ No
└>
If Yes, Congestive heart failure at admission:
□Yes □ No
Stroke
Cerebrovascular accident:
□Yes □ No
└> If Yes,
□Unresponsive coma lasting greater than 24 hours
□CVA -symptoms greater than 72 hours after onset
□RIND -recovery within 72 hours
□TIA -rec overy within 24 hours
□Non invasive carotid test with greater than 75% occlusion
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Colorectal Cancer Surgical Database
Preoperative Co-Morbidities Form
Diabetes
Diabetes:
□Yes □ No
└> If Yes,
Duration of diabetes: _______ years
Type:
□Type I
□Type II
□Type II requiring Insulin
□Yes □ No
Current insulin use:
└> If Yes, Current insulin dose ________ units
Current oral hypoglycemics use:
□Yes □ No
Diagnosed complication of diabetes:
□None
□PVD
□Neuropathy
□IHD
Renal
Renal Function Tested:
□Yes □ No
└> If Yes,
Chronic Renal Failure:
Creatinine ________umol/l
□Yes □ No
└> If Yes,
Dialysis:
□Yes □ No
└> If Yes, Duration of Dialysis ______mont hs
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Colorectal Cancer Surgical Database
Preoperative Co-Morbidities Form
Respiratory
Respiratory Di sea se:
□Yes □ No
└> If Yes, Severity:
□Mild
□Moderate
□Severe
Medication
Anti platelet agents:
□Yes □ No
└> If Yes, Days since last dose: _________days
Steroid use:
□Yes □ No
└> If Yes,
Current steroid use:
□Yes □No
└> If Yes, Current daily dose: ______ mgs
Mean daily dose in last 3 months ______ mgs
Duration of steroid use: _______ mont hs
Immunosuppre ssive agents:
□Yes □ No
└> If Yes, Type of immunosuppressant: _____________________
Cancer Hi story
Family history of colorectal neoplasia:
└> If Yes,
□Yes □ No
Number of first degree relatives ___________
Youngest age in family history: _______ years
Family history of HNP CC:
□Yes □ No
└> If Yes, Conforms to criteria: □Amsterdam II
□ Bethesda
□ Known genetic mutation
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Colorectal Cancer Surgical Database
Preoperative Co-Morbidities Form
Familial adenomatous polyposis (FAP):
Hi story of previous malignancy:
□Yes □ No
□Yes □ No
└> If Yes, Site:
History of previous colorectal malignancy:
□Lung
□Head and neck
□Hepatobilliary
□Breast
□Gynaecological
□Prostate
□Sarcoma
□Other ____________________
□Yes □ No
└> If Yes, Site:
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□Appendix
□Caecum
□Ascending colon
□Hepatic flexure
□Trans verse colon
□Splenic fixture
□Descending colon
□Sigmoid colon
□Rectosigmoid
□Rectum upper third
□Rectum mid third
□Rectum lower third
□Unknown