Ostomy Registration

Please fill out the form below to register. All fields marked with * are required.

Section 1: Personal Information

First Name: *

Last Name: *

Date of Birth: (Clink on the year to change the birth year)

Nationality:

ID Type: *
South African ID
Passport

SA ID / Passport Number: *

Ethnicity:

First language:

Second Language:

Gender: *

Religion:

Medical Insurer:

Insurance Number:

Insurance Plan:

Phone Number: *

Do you have WhatsApp?

Email Address:

Address Line 1: *

Address Line 2:

Suburb: *

City: *

Postal Code:

Province: *

Section 2: Stoma Information

Hospital of Stoma Surgery:

Where do you get your monthly supplies:

For How Long Do You Have Your Stoma?

Is Your Stoma Permanent or Temporary?

If You Have A Temporary Stoma, For How Long Are You Waiting On A Reversal

What is the reason for getting a stoma?

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Section 3: Stoma Assessment

How Long Ago Did A Stoma Nurse Look At Your Stoma And Peristomal Skin?

Which Brand Of Stoma Pouches Do You Use?

How Many Stoma Pouches Do You Receive Per Month From Your Stoma Clinic?

Do You Receive Supporting product Such As Rings, Tape, Adhesive Remover, etc

On Average, For How Long Does Your Pouch Stay On?

Does Your Pouching Systems Leak?

If You Do Suffer From Leaks, How Often Do They Happen?

Do You Smell When Wearing Your Pouch?

After How Many Days Does Your Pouches Start To Smell?

Does The Skin Around Your Stoma Burn or Itch?

Have You Been Given Advice By Your Stoma Nurse On How To Manage the Itch or Burn?

Do You Have Sores On Your Skin Around The Stoma?

Have You Been Given Advice By Your Stoma Nurse On How To Manage The Sores?

Have You Ever Eaten Less To Make Your Pouches Last Longer?

Do You Feel You Are Receiving Adequate Clinical Care?

If You Answered No, Please Explain?

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Section 4: Living Conditions

What best describes your current support system at home and in your personal life?

What is your current living arrangement?

Employment:

Other Employment:

How would you describe your financial situation?

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