Professional Documents
Culture Documents
Fever
Vertigo (Dizziness)
Stools Blood
Incontinence
Mucus Discharge
Pus
Melena (black tarry
feces)
Food Intolerance
Appetite loss
Dysphagia
(Difficulty Swallowing)
Lactose Intolerant
(Unable to eat dairy)
Crohns
Irritable Bowel
Syndrome
Colitis
Celiac Disease
Diverticula
Heart Burn
Acid Reflux
Belching
Nausea
Vomiting
Hematemesis
(Vomiting blood)
Bloating
Weight Change
Anemia
Constipation
Need for laxatives
Enema Use
Diarrhea
2. Please record ALL medications
Medication Name
Cancer
Polyps
Bowel Surgery
Rectal Pain
Others, please
explain:
Daily Dose
Name of Drug
Start
Date
YES
Type of Reaction
NO
Name of Food
YES
YES
Type of Reaction
NO
NO
NO
NO
Condition
Communicable
Aids)
No
diseases
(Hepatitis/HIV
Insulin or Pills
Cardiovascular disease
YES
NO
Polyps
YES
NO
Cancer
YES
NO
If yes, please specify:
1-Relation:___________________Cancer of the: ___________at Age: __________
2-Relation:___________________Cancer of the: ___________at Age: __________
3-Relation:___________________Cancer of the: ___________at Age: __________