Use with GI symptoms Patient Questionnaire
yo with gastrointestinal symptoms:
Initial questions
-Sx include:
-Sx started ago
-Sx started when/while
-Last BM was ago and consistency was , and color was described as .
-#BMs in past 24hrs:
-Last meal eaten was ago
-Sx improved by
-Sx worsened by
-Since onset, sx have
Add'l questions
-Other Associated Symptoms:
-- <-- Chest pain or chest/belly pain with breathing
-- <-- Black or bloody stool
-- <-- Fever
-- <-- Dysuria
-- <-- Urinary frequency
-- <-- Urinary urgency
-- <-- Hematuria

-Hx of these conditions:
-- <-- Gall Bladder or liver disease
-- <-- GERD
-- <-- Peptic ulcer(s)
-- <-- Pancreatitis
-- <-- Kidney stones
-- <-- Urinary tract infections
-- <-- Diverticulitis
-- <-- Inflammatory Bowel Disease
-- <-- Pelvic Infection
-- <-- Vascular disease

-Hx of these surgeries:
-- <-- Appendectomy
-- <-- Cholecystectomy

-Currently using: pertinent meds/substances
-- <-- Daily or near-daily use of NSAIDs
-- <-- Daily or near-daily alcohol use
-- <-- Daily or near-daily use of Opioids
-- <-- aortic aneurysm history or risk (age over 60, tobacco history)

For use in CRDAMC FM clinic
display/hide references

Result - Copy and paste this output: