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Appointment endoscopy

Please use this form to schedule an appointment for an endoscopy. By completing the questions below, we can prepare the examination carefully and safely.

1. General data

First name and surname *

Date of birth *

National registry number

Phone number *

Email address *

GPname + practice

Referring specialist

2. Desired research

What research has been requested? *Gastroscopy (stomach examination)Coloscopy (bowel examination)Combined gastroscopy & colonoscopy

Was this examination requested by a doctor? *YesNo

Reason for investigation / complaints *

3. Complaints and medical indication

Do you currently have one or more of the following complaints?Abdominal painHeartburn / refluxNausea or vomitingSwallowing complaintsBlood in stoolsBlack stoolsChange in stoolsUnexplained weight lossAnaemiaDiarrhoeaObstipationOther, namely:Multiple answers possible

Other complaint

4. Previous studies

Have you had an endoscopy before? *NoYes, gastroscopyYes, colonoscopyYes, gastro- and colonoscopy

If so, when and where?

Were there any peculiarities or complications?

5. Medication

Are you currently taking medication? *NoYes, namely:

Medications:

Do you use blood thinners? *NoYes, namely:

Blood thinners:

Are you taking diabetes medication or insulin? *NoYes

6. Allergies and hypersensitivities

Do you have any allergies or hypersensitivities? *NoYes, namely:

Allergies or hypersensitivities:

Allergy to medication or anaesthesia/sedation? *NoYes

7. Sedation (intoxication)

Would you like the examination to be performed with sedation? *YesNoDon't know yet

Have you been sedated before? *NoYes, without any problemsYes, with problems (explanation)

Notes:

8. Medical background

Do you have any of the following conditions? *Heart diseaseLung disease (asthma/COPD)Neurological disorderSleep apnoeaKidney diseaseLiver diseaseCoagulation disorderPregnancyNone of the above

Under treatment by a specialist?

9. Practical matters

Are you mobile independent? *YesNo

Are you a member of the Belgian Mutual Health Service? *YesNo

10. Consent & agreement

Consent & agreement *

Important information and agreement: An endoscopy (gastroscopy, colonoscopy or combination examination) requires specific preparation.
This preparation is essential to perform the examination safely and reliably. After making the appointment, you will receive detailed instructions by e-mail. Without proper preparation, the examination cannot take place and the appointment must be rescheduled. This may lead to unnecessary waiting time and additional costs.

Accord 2 *

I certify that the above information has been entered truthfully.

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