Dr. Arthur Grillas Recall – South Eastern Gastroenterology (SEG)

Name *

First

Last

Date of Birth *//

Contact Number *

Email *

Clinical Questionnaire

1. What was your recall for? *

Gastroscopy
Colonoscopy
Gastroscopy and Colonoscopy
Capsule Endoscoscopy

2. Have you had major chest pain or a heart attack within the past 3 months? *

Yes
No

3. Have you had a stroke within the past 3 months? *

Yes
No

4. Do you have problems performing your daily chores or shopping without getting short of breath?

Yes
No

5. Do you take blood thinning medication? *

Yes
No

If you answer no to Q5, please skip to Q8.

6. Please select your blood thinning medication from the following:

Other

Please advise if you are taking any other blood thinning medication other than the blood thinners mentioned above.

7. Are you older than 75? *

Yes
No

8. Are you diabetic requiring any form of medication? *

Yes
No

9. Do you have any concerns about your fitness for anaesthetic? *

Yes
No

10. Do you have any concerns about the needs for this procedure? *

Yes
No

11. Do you have a Private Health Fund or are you a Public Patient? *

Private Health Fund
Public Patient

Please upload your new referral from your GP.

A valid referral must be submitted to proceed with your procedure with our specialists. Please contact our office on 02 9398 0200 if you have any questions. If you are having problems uploading your referral, please email it to admin@segsydney.com.au.

Recall Please fill in the information below and we will be in contact with an appointment or procedure date.

Clinical Questionnaire