General Intake Form

Gastroenterology Intake Form

Personal Information

Patient Name *

Patient Date of Birth *

Main symptom for visit

What brings you in today? *

How long have you had this? * Please select one, then specify how many days/weeks/months/years

Days
Weeks
Months
Years

Days *

Weeks *

Months *

Years *

How often does it happen? *

Daily
Always
Other

If other, please indicate how often

Most frequent times of day *

Upon waking
Daytime
Evening
After eating
At night
Random

Testing *

None
Imaging
Blood work
Endoscopy
Urine studies
Stool studies

Treatments *

Medications
Food Changes
Other

If other, please indicate what treatments

Constitutional

Decreased appetite *

Yes
No

Fatigue *

Yes
No

Fever *

Yes
No

Weight loss *

Yes
No

Ears, Nose, Throat

Mouth Sores *

Yes
No

Sore Throat *

Yes
No

Trouble Swallowing *

Yes
No

Voice change/hoarseness *

Yes
No

GI

Abdominal distension *

Yes
No

Abdominal pain *

Yes
No

Blood in stool *

Yes
No

Constipation *

Yes
No

Diarrhea *

Yes
No

Nausea *

Yes
No

Rectal pain *

Yes
No

Vomiting *

Yes
No

Neurological

Headaches *

Yes
No

Light-headed/dizziness *

Yes
No

Seizures *

Yes
No

Syncope/fainting *

Yes
No

Psychiatric

Behavior problem *

Yes
No

Depression *

Yes
No

Nervous/anxious *

Yes
No

Musculoskeletal

Joint Pain *

Yes
No

Back Pain *

Yes
No

Gait Problem *

Yes
No

Skin

Pale *

Yes
No

Rash *

Yes
No

Jaundice/yellow skin *

Yes
No

GU

Pain with urination *

Yes
No

Urine accidents *

Yes
No

Urine decreased *

Yes
No

Respiratory

Cough *

Yes
No

Difficulty Breathing *

Yes
No

Heart

Chest pain *

Yes
No

Palpitations *

Yes
No

Allergy

Environmental allergies *

Yes
No

Food allergies *

Yes
No

Eyes

Eye redness *

Yes
No

Endocrine

Frequent urination *

Yes
No

Hematologic

Bruises easily *

Yes
No

Other recent symptoms

Prove that you're human. *