Full Name*: Last 4 characters of NRIC Number*: Mobile Number Email Address Are you able to climb 1 flight of stairs (estimate 12 to 16 steps) easily? YesNo Did you have any stroke or heart attack in the last 6 months? YesNo Do you have sleeping disorder like sleep apnea? YesNo Do you take more than 14 units of alcohol (estimate 5 ½ x 660 ml bottles) per week? YesNo Do you have any stomach / intestinal issues to consult with doctor? (estimate 5 ½ x 660 ml bottles) per week? YesNo Are you currently taking any blood thinner, other than Aspirin? YesNo Are you currently taking any iron pill? YesNo The overall risk of colonoscopy under moderate sedation is very low and considered generally a safe procedure with <1% risk from study that involved 2.8 million patient who underwent colonoscopy. Complications to Note: • Bleeding or perforation may require repeat colonoscopy, surgery or hospitalization • Small lesions in the colon can be missed when the bowel preparation is sub-optimal and your doctor may advise repeat procedure • Piles ligation carried a risk of bleeding and post procedure pain of up to 20% but are normally self-limiting • Advanced polypectomy carries an additional risk of bleeding up to 2 weeks after the procedure • Moderate sedation is very safe with minor complications occurs in about 0.3% of patients. This includes hypotension and oxygen desaturation during the course of sedation, but this is usually transient and self limiting. It is associated with a 0.01% risk of major complications such as heart attack and stroke, usually in the elderly patient with pre-existing heart disease. Risk of death is reported at about 0.005%. Let Us Know Your Preference Preferred Day: MondayTuesdayWednesdayThursdayFridaySaturday Preferred Time: 0830090009301000103011001130120012301300133014001430150015301600163015001530160016301700 Email Colonoscopy Result: YesNo This is some normal paragraph text, and this word is bold for decoration.