TABLE 2.
Q12) Does the patient have any of the following alarm symptoms/features (check all that apply)? |
a) Abdominal mass |
b) Age > 50 years |
c) Dysphagia |
d) Occult blood positive |
e) Anemia |
f) Bloody diarrhea |
g) Melena/rectal bleeding |
h) Hematemesis |
i) Persistent vomiting |
j) Jaundice |
k) Unexpected weight loss |
l) Other |
m) None |
Q13) Symptoms/signs excluding alarm symptoms you selected previously (check all that apply) |
a) Heartburn/reflux |
b) Heartburn/reflux despite optimal therapy |
c) Odynophagia |
d) Chest pain |
e) Epigastric pain |
f) Dyspepsia |
g) Abdominal pain |
h) Abdominal pain despite optimal therapy |
i) Anorectal pain or discomfort |
j) Constipation |
k) Constipation alternating with diarrhea |
l) Diarrhea |
m) Frequent evacuation |
n) Sensation of incomplete evacuation |
o) Fecal incontinence |
p) Mucus in stool |
q) Other |
r) None |
Q14) Examination/test results (check all that apply) |
a) Test results normal |
b) Abnormal physical exam |
c) Abnormal radiologic results |
d) Abnormal bloodwork |
e) Abnormal endoscopy |
f) Other abnormal result |
g) None |
Q15) Patient’s past GI history (check all that apply) |
a) Acid/peptic disorder |
b) Small intestinal disorder |
c) Hepatobiliary disorder |
d) IBD |
e) Other (non-IBD) colonic disorder |
f) Colon cancer |
g) Other |
h) None |
Q18) How concerned are you about the possibility of neoplastic disease in this patient? |
a) Not concerned |
b) Somewhat concerned |
c) Very concerned |
Q19) (Listed) below are the reasons for referral you just selected for this patient. From this list please choose the primary/most important reason for referral of the patient. |
GI Gastrointestinal; IBD Inflammatory bowel disease; Q Question number