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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 Page 1 of 5 □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 Page 2 of 5 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 Page 3 of 5 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 Page 4 of 5 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: Page 5 of 5 □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