Common Anal Conditions · Version 2.0
Appendix A — Master Referral Form
Dr. Tamer Rushdy Elalfy · 2 min read
Photocopy or adapt for local use. Complete every section; tick boxes where relevant. Describe findings by anatomical quadrant and distance from the anal verge.
| Section | Details |
|---|---|
| Patient | Name: ____________________ ID: ____________ Date of birth: ___________ Sex: ____ |
| Referral | Date and time: __________ Referrer (name, role, contact): ______________________ Referred to: __________________ |
| Urgency | ☐ 🔴 Emergency ☐ 🔴 Same-day ☐ 🟡 Urgent (≤ 2 weeks / suspected-cancer pathway) ☐ 🟢 Routine |
| Presenting complaint | Main problem: ______________________________ Duration: ____________ |
| Symptoms | ☐ Pain ☐ Bleeding ☐ Lump ☐ Discharge ☐ Prolapse ☐ Itch ☐ Constipation ☐ Diarrhoea Continence: gas / liquid / solid · passive / urge · pads per day: ____ · score (Wexner / St Mark’s): ____ |
| Alarm features | ☐ At or above screening age, not screened ☐ Iron-deficiency anaemia ☐ Weight loss ☐ Bowel-habit change ☐ Family history of CRC ☐ Abdominal, rectal, or anal mass ☐ Non-healing ulcer or plaque ☐ Positive FIT (value ____) ☐ Inguinal nodes ☐ Fever or sepsis |
| Examination | Position ________ Chaperone ________ Inspection: ______________________ DRE — resting tone ____ squeeze ____ push ____ mass/tenderness ____ Anoscopy: ______________________ Groins: ______________________ |
| Relevant history | ☐ IBD ☐ Previous cancer ☐ HIV ☐ Immunosuppression ☐ Pregnant / breastfeeding ☐ Previous anorectal surgery ☐ Obstetric sphincter injury ☐ Pelvic radiotherapy ☐ Diabetes |
| Medications | ☐ Anticoagulant (agent, dose, last dose): ______ ☐ Antiplatelet: ______ ☐ SGLT2 inhibitor ☐ Opioids ☐ Immunosuppressants / biologics ☐ PDE5 inhibitor Other: ______ |
| Investigations done | Hb ____ MCV ____ ferritin ____ CRP ____ FIT ____ calprotectin ____ STI/HIV tests ____ imaging ____ last colonoscopy (date/result) ____ |
| Working diagnosis | Most likely: __________________ Differential: __________________ |
| Treatment so far | What, how long, response: ____________________________________ |
| Reason for referral | ____________________________________________________________ |
| Specific question | For example: “Please assess for EUA and biopsy of a non-healing left lateral ulcer.” ______________________ |
| Safety-net | ☐ Patient informed of referral and urgency ☐ Written return advice given ☐ Review date: ______ |