---
title: Chronic Radiation Proctitis Screening Form - Post-Pelvic Radiation Assessment Template | Paperform
description: Professional chronic radiation proctitis screening form for assessing rectal bleeding after pelvic radiation, endoscopy criteria, hyperbaric oxygen eligibility, and gastroenterology referral coordination.
url: "https://paperform.co/templates/chronic-radiation-proctitis-screening-assessment-form"
type: static
generatedAt: "2026-03-28T00:43:19.220Z"
---

[← Back to free form templates](/templates/)    ![Chronic Radiation Proctitis Screening & Assessment Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/chronic-radiation-proctitis-screening-assessment-form.png)
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### Comprehensive Chronic Radiation Proctitis Screening for Radiation Oncology and Gastroenterology Practices

Chronic radiation proctitis is a significant late complication affecting patients who have undergone pelvic radiation therapy, particularly for prostate, cervical, rectal, or bladder cancers. This **Chronic Radiation Proctitis Screening & Assessment Form** is designed to help healthcare providers systematically evaluate patients presenting with post-radiation rectal symptoms, assess bleeding severity, determine endoscopy indications, evaluate hyperbaric oxygen therapy (HBOT) eligibility, and coordinate appropriate gastroenterology referrals.

#### Why This Form Matters for Healthcare Providers

Between 5-20% of patients who receive pelvic radiation develop chronic radiation proctitis, often months or even years after treatment completion. Early identification and appropriate intervention can significantly improve quality of life and prevent complications such as severe anemia, transfusion dependence, and emergency hospitalizations.

This template streamlines the assessment process by capturing:

 - **Radiation treatment history** including total dose, fractionation, and time since completion
 - **Detailed symptom evaluation** with validated bleeding severity scales
 - **Quality of life impact** assessment
 - **Clinical examination findings** and vital signs
 - **Laboratory values** for anemia and coagulation status
 - **Endoscopy readiness** screening and contraindication assessment
 - **HBOT eligibility criteria** including chamber availability and contraindications
 - **Referral prioritization** for gastroenterology consultation

#### Perfect for Radiation Oncology, Gastroenterology, and Primary Care

This form is ideal for:

 - **Radiation oncologists** conducting post-treatment surveillance and managing late effects
 - **Gastroenterologists** receiving referrals for bleeding or suspected radiation injury
 - **Colorectal surgeons** evaluating patients for procedural intervention
 - **Primary care physicians** identifying patients who need specialist referral
 - **Hyperbaric medicine specialists** screening candidates for HBOT
 - **Oncology nurse navigators** coordinating multidisciplinary care

The form employs conditional logic to guide appropriate clinical pathways based on symptom severity, ensuring urgent cases receive expedited attention while optimizing resource allocation for routine assessments.

#### Evidence-Based Assessment Criteria

The template incorporates recognized clinical criteria including:

 - **RTOG/EORTC late radiation morbidity scoring** for standardized severity grading
 - **Common Terminology Criteria for Adverse Events (CTCAE)** bleeding grades
 - **Hemoglobin thresholds** for transfusion consideration
 - **HBOT selection criteria** based on Undersea and Hyperbaric Medical Society (UHMS) guidelines
 - **Endoscopic intervention indicators** for argon plasma coagulation, formalin application, or other therapies

#### Streamline Patient Management with Paperform and Automation

This Paperform template does more than collect data—it actively supports clinical decision-making through intelligent conditional fields that reveal relevant sections based on patient responses. For example, severe bleeding automatically triggers urgent referral pathways, while mild symptoms guide toward conservative management.

**Enhance your workflow with [Stepper](https://stepper.io)**, Paperform's AI-native workflow automation tool. Configure automated actions such as:

 - Sending urgent alerts to on-call gastroenterologists when critical bleeding is reported
 - Automatically scheduling endoscopy appointments for eligible patients
 - Routing HBOT candidates to hyperbaric medicine coordinators
 - Creating follow-up task reminders in your practice management system
 - Populating patient charts in your EHR with structured assessment data
 - Triggering patient education emails with condition-specific resources

For practices requiring signed consent for endoscopy or HBOT, **[Papersign](https://papersign.com)** integrates seamlessly to send consent documents immediately after form completion, maintaining a complete audit trail linked to the original assessment.

#### HIPAA-Compliant Data Collection

While Paperform itself is not HIPAA compliant, this template is designed with healthcare privacy best practices in mind. Organizations using Paperform for healthcare data should ensure they have appropriate Business Associate Agreements in place and implement necessary security controls for protected health information. The structured format facilitates easy transfer to compliant systems via integrations with platforms like Airtable, Google Sheets, or direct webhook connections to HIPAA-compliant databases.

#### Improving Patient Outcomes Through Better Assessment

Chronic radiation proctitis can significantly impact quality of life, with patients experiencing frequent bleeding, urgency, tenesmus, and anxiety about their symptoms. This comprehensive screening form ensures no critical element is overlooked, supporting evidence-based management decisions that can include:

 - Medical therapies (sucralfate enemas, anti-inflammatory agents)
 - Endoscopic interventions (APC, cryotherapy, radiofrequency ablation)
 - Hyperbaric oxygen therapy for refractory cases
 - Surgical options for severe, treatment-resistant disease

By standardizing the assessment process across your practice or health system, you create consistency in care delivery, facilitate research and quality improvement initiatives, and ensure patients receive timely, appropriate interventions.

#### Trusted by Healthcare Providers Nationwide

Over 500,000 teams worldwide trust Paperform for their form and workflow needs. Healthcare organizations particularly value Paperform's intuitive interface that allows clinical staff to build and modify forms without IT support, alongside robust security features including SOC 2 Type II compliance, SSO capabilities, and role-based permissions for team access control.

Whether you're a solo practitioner tracking radiation late effects or a large cancer center coordinating multidisciplinary care, this template provides the structure and flexibility to support excellent patient care while reducing administrative burden on your team.
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