Intestinal Ultrasound referral
Referring doctor name
*
First Name
Last Name
Referring Doctor's Provider Number
*
Referring Doctor Specialty
General Practitioner
Gastroenterologist
Other
Practice Address
*
Practice Name
Street Address
City
State
Post Code
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Non Binary
Body Mass Index
< 30 kg/m2
30 - 35 kg/m2
> 35 kg/m2 - please consider if IUS is the best modality
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Inidcation
*
Crohn's Disease
Ulcerative Colitis
Suspected IBD
Non IBD
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Crohn's Disease
L1 : Ileal
L2 : Left Colon
L2 : Right Colon
L2 : Pancolitis
L3 : Ileal & left colon
L3 : Ileal & right colon
L4 : Jejunal
L4 : Upper GI
P1 : Perianal Fistula
Unknown
Crohn's Disease behaviour
Inflammatory (B1)
Stricturing (B2)
Penetrating / Fistulising (B3)
Unkown
Ulcerative Colitis
Please Select
C1 : Proctitis
C2 : Left sided Colitis ( to splenic flexure)
E3 : Extensive Colitis
Unkown
Active Disease
Yes - clinical symptoms
Yes - Faecal Calprotectin > 150ug/g
Yes - Endoscopic Inflammation
Yes - Histologic inflammation
Yes - MRE inflammation
No - Remission
Not clear
Clinical Details
Current Medications
Sulfasazline
Mesalazine (oral)
Mesalazine (topical)
Prednisolone
Budesonide (oral)
Budesonide (topical)
Azathioprine
6-Mercaptopurine
Methotrexate
Infliximab
Adalimumab
Ustekinumab
Vedolizumab
Tofacitinib
Upadacitinib
Ozanimod
Etrasimod
Other
Other Medication(s)
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Previous bowel surgeries
No
Isolated small bowel resection
Ileocaecal resection
Right Hemicolectomy
Left Hemicolectomy
Subtotal colectomy
Ileal Pouch Anal Anastomosis (IPAA)
Other
Non IBD indication
Suspected SIBO
Suspected constipation and faecal loading
Ileal ulcers for monitoring
Iron deficiency anaemia- otherwise normal gastroscopy and colonoscopy
Current Symptoms
*
Urgency
PR bleeding
Diarrhoea
Bloating
Constipation
Abdominal pain
Nausea and delayed emptying
Other
Clinical details
Relevant Clinical Records and investigations
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Desired timeframe for ultrasound
*
Urgent(ASAP)
Within 6 weeks
In 3 months
In 6 months
In 12 months
Preferred ultrasound appointment
Tuesday Morning
Friday Morning
Friday afternoon
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