PATIENT QUESTIONNAIRE
What concerns you most? (1 answer possible) ○ Possible inconvenience of the colonoscopy ○ Possible inconvenience of the sedation ○ Possible inconvenience of the purgative
I informed myself of the possible risks/adverse events of a colonoscopy ○ It applies ○ It barely applies ○ It is not the case
I informed myself of the possible risks/adverse events of a sedation (twilight sleep) ○ It applies ○ It barely ○ It is not the case
I informed myself of the possible risks/adverse events of a purgative ○ It applies ○ It barely applies ○ It is not the case
This is my first colonoscopy ○ yes ○ no
I consumed the first portion of the purgative ○ on ______ from (time) _____ until (time) _____ ○ I additionally consumed the amount of _____ liters ○ I consumed the entire amount of the purgative   □ _yes   □ _no
I consumed the second portion of the purgative ○ on ______ from (time) _____ until (time) _____ ○ I additionally consumed the amount of _____ liters ○ I consumed the entire amount of the purgative   □ yes   □ no
I adhered to the nutritional recommendations (no whole grain products, no muesli, no salads, no berries/grapes, no tomatoes/pickles/bell peppers, no onions, no corn, etc.) ○ The day of the colonoscopy ○ The day before colonoscopy ○ Two days before colonoscopy ○ Three days before colonoscopy ○ Four days before colonoscopy ○ Five days before colonoscopy ○ I did not adhere to the nutritional recommendations
I ate the following products ______ Last _____ days before the examination
I would prefer to consume the purgative the following way ○ Half of the purgative the day before, half the day of colonoscopy ○ The total amount of the purgative on the day of colonoscopy
I experienced the taste as ○ Neutral ○ Better than expected ○ Worse than expected
Overall I experienced the purgative as ○ Neutral ○ Better than expected ○ Worse than expected
What would discourage you most to consume the entire volume of the purgative? ○ Bad taste ○ Too large volume of liquid intake ○ Bad smell ○ Inconvenient color
What would be the maximum volume of purgative you would consume ○ 0.5 liter ○ 1 liter ○ 2 liter ○ 3 liter ○ 4 liter ○ >4 liter
If I had the choice I would for the next colonoscopy ○ use this purgative again ○ use a different purgative
If you would prefer another purgative, what qualities would you prefer ○ better taste ○ less volume to drink ○ others ____