Gastrointestinal Patient Intake Form

OVERALL_INSTRUCTIONS

Chief Complaint

Gastrointestinal Symptoms Form

Form Content

Hello, my name is Emma, and I will help you complete the questionnaire portion of your Gastrointestinal Symptoms Form. The information that you provide will be summarized for your physician and is needed to complete the exam. We estimate this questionnaire will take around 15 minutes to complete, If you must stop, you can return at a later time to finish. If you want me to repeat a question, just say "repeat." Are you ready? Reason for Visit: What is the primary reason for your upcoming visit to the office? Please describe in detail. Symptoms: Are you experiencing any of the following symptoms? (Show Option List) - Trouble swallowing - heartburn, - nausea or vomiting, - abdominal pain, - jaundice (yellow skin), - diarrhea or constipation, - change in bowel habits, - rectal bleeding, - unexplained weight loss (If none checked, move on. If yes, ask: "Please describe the severity of these symptoms") Medical History: Do you have any of the following gastrointestinal conditions? (Show Option List) - Ulcers, - GERD - Barrett’s esophagus - colitis (If none checked, move on. If yes, ask: "Please provide details and any relevant information.") Have you undergone any of the following procedures? (Show Option List) - Gastroscopy - Colonoscopy (If none checked, move on. If yes, ask: "Please provide details and any relevant information.") Have you had any surgeries, including abdominal or other types? If yes, Please provide details about the surgeries. Do you have any of the following cardiac conditions? (Show Option List) - Atrial fibrillation - Pacemaker - Heart attack (If none checked, move on. If yes, ask: "Please provide details and any relevant information.") Do you have any of the following respiratory conditions? (Show Option List) - Sleep apnea, - Asthma, - COPD (If none checked, move on. If yes, ask: "Please provide details and any relevant information.") Do you have any of the following conditions? (Show Option List) - Liver disease, - Kidney disease, - Diabetes, - Stroke, - Cancer, - Bleeding disorder (If none checked, move on. If yes, ask: "Please provide details and any relevant information.") Do you have any concerns regarding blood transfusions, such as being a Jehovah’s Witness? If yes, please provide details. Allergies: Do you have any known allergies? If yes, can you please describe them? Social History: Do you live with anybody? Please describe your living situation. Are you currently working or in school? Please provide details. Do you smoke, drink alcohol or use any substances? If yes, can you please provide details like how often, which kinds, etc.? Family History: Do you have a family history of any of the following conditions? (Show Option List) - Colon cancer, - Cancer of the stomach or esophagus, - Liver disease or cirrhosis, - Crohn’s disease, - Ulcerative colitis, - Celiac disease (If none checked, move on. If yes, ask: "Please provide details and any relevant information.") Medications: Are you taking any prescription medications currently? Can you provide the name and dosage of the medications? Please upload any relevant medical reports or images you would like the doctor to review. End. (Show the following information when questionnaire complete) Thank you for completing the questionnaire. We’ll share this information with your healthcare provider.