Name *

First Name

Last Name

Contact No *

(###)

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Date of Birth *

MM

DD

YYYY

Contact Number *

(###)

###

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Patient Emergency Contact

(###)

###

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Patient Emergency Contact No

(###)

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Diagnosis of

Constipation (slow transit, opioid, IBS-C, idiopathic)

Faecal incontinence (urge/urgency, passive, post defaecation)

Low anterior resection syndrome (LARS)

Evacuation difficulties (obstructed defaecation)

Neurological (SCI, MS, Parkinson’s, spina bifida, cauda equina)

Has a Bowel Assessment Form been completed? *

Yes

No

Has the patient had a DRE? *

If YES mention date of last DRE

Yes

No

Date of Last DRE

MM

DD

YYYY

Endoscopic or PR investigation performed (Required for Surgical History) *

Yes

No

Has the patient had bowel/rectal surgery in the last 3 months: *

Yes

No

Diagnosis of bowel malignancy *

Yes

No

Is Rectal Bleeding Present? Is it caused by a known Haemorrhoid or Fissure? *

If No Do Not Use

Yes

No

Does the patient suffer from Inflammatory Bowel Disease? *

Yes

No

Impacted/Heavily constipated (Requirement to clear bowels prior to Education commencing) *

Yes

No

Does patient have any of the absolute contraindication conditions (see below)? *

If Yes Do Not Use

Yes

No

Does the Patient consented to being contacted? *

Yes

No

Does patient have any of the relative contraindications (see below)? *

If Yes please attach letter from Consultant outlining consent. RELATIVE CONTRAINDICATIONS Rectal irrigation is not recommended for:

• Children below 3 years of age
• Pregnancy or planned pregnancy or breast feeding
• Inflammatory bowel disease (e.g. Crohn’s disease or ulcerative colitis)
• Active perianal sepsis (fistula or abscess, third or fourth degree haemorrhoids)
• Previous rectal or colonic surgery
• Diarrhoea of unknown aetiology
• Faecal impaction/rectal constipation
• Severe autonomic dysreflexia
• Severe diverticulosis or diverticular abscess
• Abdominal or pelvic irradiation
• Long term steroid therapy
• Anti-coagulant therapy
• Low blood sodium
• Previous severe pelvic surgery
• Colonic biopsy within the past 3 months
• Use of rectal medications for other diseases which may be diluted by irrigation
• Congestive cardiac failure

Yes

No

Does patient have any below contraindications? *

CONTRAINDICATIONS Irrigation should not be used under the following circumstances (absolute contraindications):

• Known anal or colorectal stenosis
• Colorectal cancer/pelvic malignancy pre surgical removal
• Acute inflammatory bowel disease
• Acute diverticulitis
• Within 3 months of anal or colorectal surgery
• Within 4 weeks of endoscopic polypectomy
• Ischaemic colitis

Yes

No