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- When you print this information it is important that you choose the morning or afternoon preparation depending on the time of the procedure.
- After you have printed off the sheets under "afternoon" or "morning" as appointments you should also print off "general", "tips", "safety" and "questionnaire" to complete your handout.
- PLEASE USE THE "PRINTER FRIENDLY" BUTTON TO GET A PRINTABLE PAGE.
- You should read all these forms carefully. If there is any confusion you should ring my rooms at 55913155.
DR DAVID ROBINSON
COLONOSCOPY
To make the procedure as easy as possible it would help if you could answer the following questions:
- Do you understand what is being done, and why?
YES/NO
- Do you understand the risks associated with
this procedure? YES/NO
- Do you understand that polyps if found may
have to be removed? YES/NO
- Are you satisfied that your preparation was
successful?
YES/NO
- If you are female is there any possibility
that you could be pregnant
(it is important that you inform the Dr accordingly). YES/NO
- Do you suffer from any of the following problems:
| Heart disease |
Yes/No |
Asthma |
Yes/No |
Kidney disease |
Yes/No |
| Diabetes |
Yes/No |
Hypertension |
Yes/No |
Heartburn |
Yes/No |
| Angina |
Yes/No |
Emphysema |
Yes/No |
Other relevant conditions:
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___________________________________________________________
- Are you on any regular medications? If so which
ones.
(Please provide a seperate list if necessary)
__________________________________________________________________
- Do you suffer from any allergies? YES/NO
__________________________________________________________________
- Do you have a companion with you to drive you
home? YES/NO
- Are you part of the Government Bowel Screening
Program?
YES/NO
I have read and understand all the information I have been
given in these sheets.
I CONSENT to Dr David Robinson performing the procedure
as outlined and understand the risks involved.
PATIENT
NAME: __________________
SIGNATURE:
_____________ _______ |
DATE OF
BIRTH: _________ |
| DOCTOR'S
SIGNATURE: ____________________________ |
DATE: _________________ |
PLEASE FILL IN AND BRING WITH YOU ON THE DAY OF PROCEDURE
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