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 = Rectum 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) Carcinoid tumor…………………………………………………………..……_____
e) Carcinoma……………………………………………………………….……._____
f) Lymphoid hyperplasia………………………………………………..……….._____
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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