PR Bleeding Referral Form

Note to GPs: This form is specifically to refer patients under age 40 that you believe have
HAEMORRHOIDS OR ANAL FISSURE to a nurse led clinic for confirmation of diagnosis and
treatment.
Contact
details:
GSTT
KCH
Other
Address
Phone
Email
Referral Date
Referring Clinician
Practice Details
~[Today...]
~[Free Text: Referring
Clinician?]
~[Surgery Address Line
1]
~[Surgery Address Line
2]
~[Surgery Address Lin3
3]
~[Surgery Tel No.]
Patient Name
DOB
~[Forename] ~[Surname]
~[Date Of Birth]
Patient Address
~[Patient Address Block]
Patient Tel
Mobile
NHS Number
Hospital Number
~[Telephone Number]
~[Mobile]~[Mobile Number]
~[NHS Number]
~[Hospital Number]
Referral Checklist
1. Have you considered 2 week wait criteria
Yes
No
2. Please indicate treatments used?
E.g. Laxatives, topical therapies (local anaesthetics/astringents/topical steroids)/ GTN ointment- for anal
fissures only
3. Date of first onset of symptoms:
4. Previous episode?
(When/ How long?)
5. PR Bleeding
(Please tick box)
Bright Red
Mixed with stool
On the tissue
6. Pain
A
Altered
Coating the stool
In the pan
Yes
No
Yes
Yes
No
No
Character
7. Mucous
8. Pruritus Ani
History of presenting complaint
Please comment on presence of; Constipation, weight loss, change in bowel habit
Include here what you consider to be the likely cause of bleeding
Past Medical history
Relevant Medications
Including over the counter laxatives/ suppositories
Allergies
Family History
Examination findings
Digital Rectal Examination
Essential prior to referral
Further Investigations
Including previous Proctoscopy or colonoscopy
Notes
Patients with first onset of symptoms after age 40 should be referred to the main colorectal clinics and have U&Es
checked and documents for quicker consideration of CTE/ colonoscopy at the clinic
Please use appropriate treatments for an adequate duration, for example GTN ointment for a maximum of 8 weeks
for anal fissures only.
Please kindly fill all sections of the form completely to avoid unnecessary delays