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Colorectal Program intake form

Our goal is to provide the best outcomes for patients with colorectal and pelvic reconstruction needs through an innovative integration of colorectal surgery, gynecology, urology and gastroenterology/motility in one center of excellence. Please help us get ready for your visit by providing the information in this health questionnaire.

We look forward to helping you!

Patient name:
Date of birth:
Parent/Guardian 1
Parent/Guardian #1 date of birth:
Parent/Guardian 2:
Parent/Guardian #2 date of birth:
Is the patient adopted?
Does the patient live in more than one household?
Does the patient have a formal custody agreement/parenting plan?

Please upload legal documentation here or email to colorectalnurse@childrensnational.org. Documentation will need to be reviewed by our legal team before moving forward with any clinical care.

Legal documentation:
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File uploads may not work on some mobile devices.
Address:
Primary care provider name:
Primary care provider location:
What is the patient's colorectal diagnosis?
How did you hear about us?
Please list any other medical diagnoses or problems

Surgical History

Please list operations that have been done in the past.

Colorectal Operations (C)

Date of surgery (C1)
Date of surgery (C2)
Date of surgery (C3)
Date of surgery (C4)

Urologic Operations (U)

Date of surgery (U1)
Date of surgery (U2)
Date of surgery (U3)
Date of surgery (U4)

Spine Operations (S)

Date of surgery (S1)
Date of surgery (S2)
Date of surgery (S3)
Date of surgery (S4)

Heart Operations (H)

Date of surgery (H1)
Date of surgery (H2)
Date of surgery (H3)
Date of surgery (H4)

Other Operations (O)

Date of surgery (O1)
Date of surgery (O2)
Date of surgery (O3)
Date of surgery (O4)

Medications and Allergies

Please list any regular medications being taken

Stool

Did the patient pass stool (meconium) within the first 48 hours of life?
How does the patient eliminate stool?
Does the patient identify when they need to have a bowel movement?
Does the patient require prompting to sit on the toilet to stool?
Does the patient frequently need to return to the bathroom within 0-60 minutes to have another bowel movement?
Has the patient had any physical or occupational therapy for troubles with stooling or urination?
ie: Working to improve stooling mechanics. Did physical therapy from 3/2023-9/2024
Is the patient having stool accidents?
When is the patient having stool accidents?
What type of stool accidents?
How often does the patient have stool accidents?
How often does the patient have a bowel movement?
Please check all gastrointestinal symptoms
the patient has had in the past six months:
Select all that apply
Is the patient doing anything to help
empty their bowels?
What is the patient doing to help
empty their bowels?
Select all that apply
Does the patient have Hirschsprung disease?
Has the patient had any recent gastroenterology/colorectal testing? Please select all known testing:
Has the patient had episodes of enterocolitis?

Urine

Has the patient had problems with
urinary tract infections (UTIs)?
Are the patient's UTIs associated with fever?
Did any UTIs require treatment
with antibiotics?
How does the patient empty their bladder?
Is the patient dry between catheterizations?
What is the urine status between caths?
Is the patient having urinary symptoms?
Select all that apply
What type of urinary accidents?
What is the timing of the accidents?
How often does the patient have urinary accidents?
Has the patient had any recent urological testing?
Select all that apply

Gynecologic Status

(If applicable)

Has the patient developed breast buds?
Has the patient started having periods?
Has the patient’s pelvic/gynecologic
anatomy been evaluated?
How was the patient's pelvic/gynecologic
anatomy evaluated?
Select all that apply

Spine Status

Has the patient’s spine been
evaluated by imaging?
How was the patient's spine evaluated
by imaging?
Select all that apply

Psychological Concerns

Is the patient currently receiving counseling,
psychological or behavioral services?
Please indicate whether any of the following have been areas of difficulty:
Select all that apply

Nutritional Concerns

Weight (kg)
Weight %
Height (cm)
Height %
Does the patient require supplemental tube
feedings or nutrition via total parenteral nutrition (TPN)?
Are the patient’s nutritional needs being met?
Would you like to meet with a dietician
during your visit?

Social Concerns

Will you be traveling from out of state/country?
Do you have a place to stay during your
visit to Children’s National?

For questions regarding housing while in Washington, D.C., please contact Nikki Scurlock

Do you have transportation to and from
the hospital?
Are you the parent or legal guardian
of the patient?

Anesthetic Concerns

Has the patient ever had any problems
with anesthesia?
Any family history of anesthesia problems?
Does the patient have a history of
difficult intubation?
Does the patient have any current or history
of cardiac problems?
Does the patient have any current or history
of pulmonary problems?
Does the patient have any current or history
of endocrine problems?
Ex: Diabetes, adrenal insufficiency, chronic steroid use
Does the patient have any current or history
of hematology/blood clotting disorders?
Does the patient have a seizure disorder?
Does the patient have any metabolic disorders?
Ex: Mitochondrial myopathy, pyruvate dehydrogenase deficiency
Does the patient have an implanted device?
Ex: AICD, pacemaker, vagal nerve stimulator
Does the patient have any diagnosed
genetic conditions?
Does the patient have a tracheostomy,
use CPAP, or require ventilator support?

If you answered yes to ANY of the above Anesthesia Concern questions, list the names and contact information for the specialist who treated your child. (A)

Ex: Asthma, diabetes, cardiac, etc.
Phone number and email if possible



Ex: Asthma, diabetes, cardiac, etc.
Phone number and email if possible



Ex: Asthma, diabetes, cardiac, etc.
A3
Phone number and email if possible



Ex: Asthma, diabetes, cardiac, etc.
Phone number and email if possible



If you are traveling and need assistance with lodging, transportation, or airfare please reach out our patient housing & amenities team via email at DrBearsLodging@ChildrensNational.org once your child’s appointment dates have been confirmed.

Insurance

Providing us with your insurance card ahead of your visit will greatly expedite the process. Please upload the front and back of of your primary and secondary (if applicable) insurance cards.

Do you have insurance?*
Please upload a copy of your insurance card - front*
No File Chosen
File uploads may not work on some mobile devices.
Please upload a copy of your insurance card - back*
No File Chosen
File uploads may not work on some mobile devices.
Do you have secondary insurance?*
Please upload a copy of your secondary insurance card - front*
No File Chosen
File uploads may not work on some mobile devices.
Please upload a copy of your secondary insurance card - back*
No File Chosen
File uploads may not work on some mobile devices.


Once you submit this form, you will be taken to the medical records release form.

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