Supplementary Endoscopy Report Form

Colorectal Cancer Screening In Patients Treated With Radiation Therapy

COLONOSCOPY FORM and PATHOLOGY REPORT Completed by:______

Date: _____/_____/_____ MRN#: ______Mo Day Year Participant Initials: ______Study Id No: ______

1. Record the size, location, type of polyp, and procedures for removal of each polyp. Indicate location of polyp(s) on diagram below using assigned polyp letters. **Note: Assess size using open biopsy forcep**

Location Shape Procedure Histology Atypia/Dysplasia CE = Cecum P = Peunculated 1 = Snare polypectomy C = Carcinoma H = High Grade Dysplasia AC = Ascending Colon S = Sessile 2 = Hot biopsy forceps N = Normal L = Low Grade Dysplasia HF = Hepatic Flexure U = Unable to be 3 = Cold biopsy H = Hyperplastic U = Unable to be TC = Transverse Colon determined, not 4 = Not removed T = Tubular determined, not mentioned SF = Splenic Flexure mentioned 5 = Lost/insufficient V = Villous N = None DC = Descending Colon M = Mixed Tubulovillous SC = Sigmoid Colon A = Adenomatous, not specified RE = U = Unable to be determined, not mentioned O = Other: ______

Polyp Location Distance (cm) Diameter Shape Procedure Histology Atypia Letters from anal verge (mm) A ______B ______C ______D ______E ______F ______G ______H ______I ______J ______

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Supplementary Endoscopy Report Form

Colorectal Cancer Screening In Patients Treated With Radiation Therapy

COLONOSCOPY FORM and PATHOLOGY REPORT Completed by:______

Date: _____/_____/_____ MRN#: ______Mo Day Year Participant Initials: ______Study Id No: ______

Code: 1 = Yes 2 = No

2. Other Results Found During the Procedure ….……………………………..……._____

If Yes:

a) Hemorrhoids …………………………….………………………….…………_____

b) Diverticula ……………………………….………………………….……….. _____

c) Chronic inflammation…………………….…………………………………..._____

d) Other, please specify: ______

3. Presence of polyp(s) in distal 60 cm (1 = Yes, 2 = No) ……………..……………_____

4. Farthest extent reached is:

a) If ≤60 cm, farthest extent visualized (cm)..………………….……….……..…_____

If > 60 cm, farthest extent visualized by location:

b) Splenic Flexure……………………………………………………….…….…._____

c) Transverse Colon…………………………………………………………..….._____

d) Hepatic Flexure……………………………………….………………………._____

e) Ascending Colon………….…………………………………………………..._____

f) Cecum …..………..……………………………………………………………_____

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Supplementary Endoscopy Report Form

Colorectal Cancer Screening In Patients Treated With Radiation Therapy

COLONOSCOPY FORM and PATHOLOGY REPORT Completed by:______

Date: _____/_____/_____ MRN#: ______Mo Day Year Participant Initials: ______Study Id No: ______Code: 1 = Yes 2 = No

5. Pathology Results

a) Lipoma………………………………………………………………………. _____

b) Inflammatory polyp………………………………………………………….._____

c) Juvenile polyp………………………………………………………………..._____

d) tumor…………………………………………………………..……_____

e) Carcinoma……………………………………………………………….……._____

f) Lymphoid ………………………………………………..……….._____

g) Other, please specify: ______

6. Presence of adenomatous polyp(s) or cancer (1 = Yes, 2 = No) …………………._____

7. Total number of adenomatous polyps………………………………………..……_____

8. Presence of adenomatous polyp(s) or cancer in distal 60 cm (1 = Yes, 2 = No) …_____

Colonoscopist: ______(Please Print Name)

Colonoscopist Signature: ______

P.I. Signature: ______

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