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Patient Name:_______________________________________________ Date:___________________________
Print this form out, complete it, and bring it to your appointment.
Instructions: In each section, check the appropriate items to indicate your current symptoms, your risk factors, and your personal/family medical history.
SECTIONS: |
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1. |
Irritable Bowel Syndrome (IBS) -Modified Rome Criteria
At least two days a week, I experience...
____change in bowel movement frequency (diarrhea, constipation)
____noticeable difference in stool form (shape, size, consistency}
____passage of mucus in stools
____bloating or feeling of abdominal distension (swelling of stomach)
____abnormal stool passage (straining, urgency, feeling of incomplete evacuation)
____first bowel movement within 30 minutes of arising
For the last 3 or more months I have experienced continuous or recurring abdominal (stomach) pain/irritation that:
____is relieved with a bowel movement
____occurs with a change in bowel movement frequency
____is related to a change in stool consistency |
2. |
Inflammatory Bowel Disease (IBO)
____Personal or family history of IBD (ulcerative colitis or Crohn's disease)
____Recurrent abdominal (stomach} pain
____Nighttime abdominal pain that interferes with sleep
____Recurrent diarrhea
____Nighttime diarrhea that interferes with sleep
____Blood in stool
____Pus in stool
____Fever
____Weight loss |
3. |
Colorectal Cancer
____Blood-related family member diagnosed with colorectal cancer
____Personal history of other cancers
____Diet high in fat, protein, calories, alcohol, and meat (both red and white)
____Diet low in fiber, calcium, or folate (green leafy vegetables)
____Sedentary (physically inactive life style)
____Overweight
____Over 50 years old
____Previous inflammatory disease of the colon (ulcerative colitis)
____Diagnosis with colon polyps
____Blood in stools
____Unexplained weight loss
____Narrow stool diameter
____Recurrent abdominal (stomach) pain
____Recurrent constipation/diarrhea
____Genetic risk of colon cancer |
4. |
Food Allergy
(Check only symptoms often experienced within 1-2 hours after eating)
____Bloating/indigestion
____Hives (skin rash)
____Headaches
____Diarrhea
____Cramps
____Abdominal (stomach) pain
____Difficulty breathing
____Nausea, vomiting
____Swollen tongue/lips |
5. |
Pancreatic Insufficiency
____Over 35 years old
____Gallstones
____Previous surgical removal of gall bladder
____Loose, watery stools
____Fatty and foul-smelling stools _Undigested food in the stools
____Nausea
____Acid reflux/heartburn
____Bloating/indigestion
____Unexplained weight loss
____Chronic abdominal (stomach) pain
____Food allergy/intolerance
____Connective tissue disease (eg, lupus, rheumatoid arthritis, Sjogren's syndrome)
____Personal or family history of cystic fibrosis
____Personal history of alcoholism, diabetes, or osteoporosis |
6. |
Parasite Infection
____Loose, watery stools
____Nausea
____Abdominal (stomach) pain _Chills/fever
____Blood or mucus in stool
____Headache
____Chronic fatigue
____Skin rash
____Excessive gas or bloating
____Vomiting
____Unexplained weight loss
____Dehydration
____Travel abroad, particularly in developing countries
____Recent exposure-via physical contact or drinking water-to potential sources of contamination: recreational water e.g., swimming pools, lakes, hot tubs I, child-care centers, hiking/camping, agricultural (animal) run-off.
____Recent contact with animals, pets |
7. |
H. pylori infection
____Burning or gnawing abdominal pain that may improve after eating but returns later
____Change in appetite with weight gain or weight loss
____Nausea or vomiting
____Frequent burping or bloating
____Regular use of alcohol or tobacco
____Previous or current anti-inflammatory therapy (eg, aspirin, ibuprofen)
____Non-ulcer dyspepsia ("sour stomach")
____Personal or family history of duodenal or gastric cancer
____Previous infection with H. pylori
____Gastroesophageal reflux (acid reflux) |
8. |
Yeast Syndrome (yeast dysbiosis)
____Recent prolonged use of antibacterial or steroid drugs, or oral contraceptives
____Sugar cravings
____Hormone-related imbalances (PMS, hypoglycemia, etc)
____Recurrent vaginal, prostate, or urinary infections
____Memory/concentration problems
____Environmental/food sensitivities
____Recurrent skin rash or irritation
____Digestive problems (gas, bloating, stomach pain)
____Chronic fatigue |
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