Physician- Test Site Feedback Survey

Questions marked with an * are required

Physician Name:

* First Name :
* Last Name :

Name of Practice:

Patient Number:

What is the date of the procedure?

Please complete after reading each patient's study.

Number of PillCam COLON studies you have read (not including training or e-learning).

studies

Reading the study:

min

Creating the report:

min

Please rate your overall level of satisfaction with the amount of time you spent reading and reporting on this study.

How would you rate the patient's bowel preparation as you read the study?

Good

Adequate

Poor