Comprehensive Gastroenterology Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: _________
• Contact Number: _____________ Email: _______________
• Primary Care Physician: _______ Referring Doctor: ________

Chief Complaint

Please describe your main reason for visit: ________________

Gastrointestinal History

Current Symptoms (check all that apply):

• Abdominal pain
• Heartburn/GERD
• Nausea/Vomiting
• Diarrhea
• Constipation
• Blood in stool
• Weight loss/gain

Previous GI Procedures

• Last Colonoscopy Date: _________ Location: _________
• Last Upper Endoscopy Date: _____ Location: _________
• Other GI procedures: __________________________

Medical History

Past Medical Conditions

• Colon polyps
• IBD (Crohn's/Ulcerative Colitis)
• Celiac disease
• Liver disease
• Stomach ulcers
• Cancer (type): _________

Surgical History

List all previous surgeries with dates:

1. _________________ Date: _________
2. _________________ Date: _________

Family History

Check if any blood relatives have had:

• Colon cancer
• Stomach cancer
• Celiac disease
• IBD
• Liver disease

Current Medications

Allergies

List all medication allergies and reactions:

Social History

• Tobacco use: [ ]Never [ ]Current [ ]Former
• Alcohol use: [ ]Never [ ]Occasional [ ]Regular
• Occupation: ________________

Review of Systems

Check any current symptoms:

General

• Fever
• Fatigue
• Weight changes

Gastrointestinal

• Difficulty swallowing
• Early satiety
• Changes in bowel habits

Other Systems

• Joint pain
• Skin problems
• Sleep issues

Patient Signature: _____________ Date: _________