Oesoph DB audit Form

Oesophagectomy Audit collection form DEMOGRAPHICS Surgery booked for: Patient Name: Partner / Spouse Name: Address Contact details of close family member or friend other than spouse ( not living in the same house) Contact Name: Relationship to pt. D.O.B. Address: Sex: UR No. Telephone Telephone: General Practitioner: ………………………………… GP telephone ……………………………. GP Address: ……...……………………………... . .………. ……………………………………. Consultant: …………………………………………. Public / Private Hospital: …………………………………………. Comorbities Details Heart disease Y / N Respiratory disease Y / N Diabetes Y / N Renal Y / N Obesity Y / N Reflux disease Y / N Duration: less than one year / 1 – 5 years / greater than 5 years Heartburn: never / once a month / few times a week / daily / Previous heartburn followed by recent disappearance of heartburn Regurgitation: never / once a month / few times a week / daily Other Y / N Smoker: Smoker / Ex smoker / Never Smoked Medications: Pack years _______ Alcohol: 0 / 1-2 / 3-5 / 6-9 / 10-15 / >15 standard drinks per week 1 standard drink = 1 glass of beer 1 glass wine Regular NSAID or Aspirin use Y / N 1 single spirit Please return completed form to Clinical Trials Assistant, University Department of Surgery, Level 5, EHB, Royal Adelaide Hospital PRESENTATION Symptoms: Duration: Dysphagia (Solids / liquids & ...