Gastrointestinal History

Yes / No

Do you have gnawing pain / burning in the stomach?

N

Between meals?

N/A

Middle of the night?

N/A.

What types of food do you avoid?

None

Have you ever vomited up blood?

N

Any recent change in bowel habits?

N

Frequency of loose bowel movements?

N/A

Problems with constipation?

N

Ever have black tarry bowel movements?

N

Excessive gas in your stomach?

N

Ever had bright red bleeding from the rectum?

N

Do you have pain with bowel movements?

N


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