Clinical trial: NCT05523271
Section: Procedures
Subsections: Endoscopy:

Date of procedure:
Endoscope system used: Intubation: Yes No Propofol: Yes, mention dosage mg No Midazolam: Yes, mention dosage mg No Blood pressure: (mmHg) O2 saturation: %
Pulse: (b/m)
Clinical trial: NCT05523271
Section: Voluntary Participation
Subsections: Informed Consent Signed:

YES NO
Date consented:
PATIENT INFO  
| Date & time of admission:   |
|-----------------------------|  
Indication for colonoscopy:
Surveillance GI Symptoms, please specify:
Per-rectal bleeding Abdominal pain Weight loss Primary CRC Screening Family history of CRC
FIT positive Other:
Drug History:
Anti-thrombotics. If yes, dose:
Others:
1. 2.  
3.  
4.  
| 5.   |
|------|