Lower GI indications for endoscopy:
(MUST tick at least one
box and attached relevant
evidence/provide comment
as indicated if referring for
colonoscopy or referral
will be returned)
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Rectal bleeding (multiple occurrences or continuous) for >4 weeks (specify time and no. of episodes below)
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+iFOBT where a colonoscopy has not been performed within last 2 years (attach results) |
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Altered bowel habit >6 weeks AND in presence of alarm symptoms (provide description and must select at least one alarm symptom below)
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Altered bowel habit >6 weeks AND age>=45 (provide description)
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Diarrhoea >6 weeks with negative stool culture (attach MC&S results)
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Unexplained iron deficiency +/- anaemia (attach FBC results)
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Mass or abnormal imaging (attach report)
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After first episode of proven diverticulitis to exclude neoplasm
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Surveillance procedures required within 12 months (specify reason & attach reports)
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Alarm symptoms for lower GI endoscopy:
(informs triage- tick all that
apply and attach evidence/
provide detail)
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Persistent rectal bleeding
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Unexplained progressive weight loss
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Bloody diarrhoea with negative stool MC&S
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Persistent severe abdominal pain
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Unexplained iron deficiency anaemia |
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Lower GI comments / evidence to support
indications:
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Upper GI Comments/ evidence to support indications |
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Medical History and Risk Factors
Height (cm): |
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Weight (kg): |
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(Estimate if not known) |
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Bleeding disorder (specify below)
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Kidney disease (Attach recent U&E)
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Neurological history (specify below)
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Recent surgery (specify below)
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Significant lung/airway disease
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Implanted defibrillator in situ For any of above in situ
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Liver disease (attach recent LFT/INR/ platelets) |
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Additional Medical History Details:
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Special
Considerations:
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Significant alcohol history
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Significant illicit drug history
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Significant mental health issues
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Other social factors e.g. homeless (detail below)
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Department of Justice patient
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Other / Comments: |
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Is the Patient taking any anti-coagulant or anti-platelet medication/s, including Aspirin?
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