Iron Questionnaire

ID for Power Automate

First Name *

LastName *

DOB *

Have you had an iron infusion in the past *

YesNo

How long ago was the last infusion? *

Did it help you feel better? *

YesNoUnsure

Did you have an side effects from the infusion? *

YesNo

Can you describe these side effects? *

Are you currently taking oral iron supplements? *

YesNo

Have you previously taken iron supplements? *

YesNo

Did oral iron supplements help you? *

YesNoUnsure

Have you had any side effects from oral iron supplements? *

YesNo

What side effects? *

Nausea/vomitingConstipationOther

Other: *

Are you currently pregnant *

YesNo

How many weeks+days pregnant are you today? *

Do you normally get heavy periods/menstrual losses? *

YesNoUnsureN/A

How many bleeding days do you get on average per cycle? *

On the heaviest day of your period, how often would you change your pad/tampon/cup etc? *

Do you have any blood in your bowels, dark/tarry motions or other bowel symtoms? *

YesNo

Please describe: *

Other: *

Have you ever had any of the following bowel procedures?

ColonoscopyGastroscopyCapsule Endoscopy

When was this last done *

Were there any abnormalities, can you outline these? *

Comments

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