Your First Proctoscopy, Sigmoidoscopy, or Colonoscopy Exam
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1. Please take a few moments to tell us about your experience!
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1
. Are you male or female?
Are you male or female?
Male
Female
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2
. What is your current age?
What is your current age?
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3
. How old were you when you had your first proctoscope, sigmoidoscope, or colonoscope exam?
How old were you when you had your first proctoscope, sigmoidoscope, or colonoscope exam?
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4
. What was the reason for the exam?
What was the reason for the exam?
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5
. Which exam were you given?
Which exam were you given?
A rigid proctoscope or sigmoidoscope exam
A flexible sigmoidoscope exam
A colonoscopy
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6
. Where was the exam performed?
Where was the exam performed?
My doctor's office
The gastroenterologist's office
The hospital
Other (please specify)
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7
. What kind of bowel prep did you have to do?
What kind of bowel prep did you have to do?
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8
. If you were given an enema before the exam, who administered it?
If you were given an enema before the exam, who administered it?
I gave it to myself
My parents or spouse administered it
I got an enema at the doctor's office before the exam
Other (please specify)
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9
. How were you clothed for the exam?
How were you clothed for the exam?
I was told to undress completely and given a backless gown to put on
I was told to remove everything below my waist and given a backless gown to put on
I was told to undress and given nothing to put on
Other (please specify)
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10
. How were you positioned for the exam?
How were you positioned for the exam?
Laying on my left side on the exam table
In the knee chest position
On my back with my feet in stirrups
On my back with my knees to my chest
Other (please specify)
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11
. Do you feel that your privacy was respected during the exam?
Do you feel that your privacy was respected during the exam?
Yes
No
If no, please explain.
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12
. Were you given sedation before the exam?
Were you given sedation before the exam?
Yes
No
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13
. Did the care provider do a digital rectal exam before the exam?
Did the care provider do a digital rectal exam before the exam?
Yes
No
14
. How painful was your exam?
How painful was your exam?
Uncomfortable but tolerable
Intermittently painful
Very painful
Unbearable
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15
. How did you feel about having your bottom exposed?
How did you feel about having your bottom exposed?
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16
. How long did the procedure take?
How long did the procedure take?
Less than five minutes
5 to 10 minutes
10 to 20 minutes
20 to 30 minutes
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17
. Please take a moment and tell us what happened during your exam.
Please take a moment and tell us what happened during your exam.
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