GCGASTRO.COM.AU - Dr Robinson - Gastroscopy Questions

General
Questionaire

It is important that you print off both forms under Gastroscopy and read both carefully.
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.

PRINTER FRIENDLY VERSION ON LANDSCAPE

GASTROSCOPY

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
Have you fasted for 6 hours prior to this procedure? YES/NO
Do you suffer from any of the following medical problems? YES/NO

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:

___________________________________________________________

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

THANK YOU FOR YOUR CO-OPERATION

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 TAKE WITH YOU ON THE DAY OF PROCEDURE