| Gastrointestinal History | Yes / No | 
| Do you have gnawing pain / burning in the stomach? |  | 
| Between meals? |  | 
| Middle of the night? |  | 
| What types of food do you avoid? |  | 
| Have you ever vomited up blood? |  | 
| Any recent change in bowel habits? |  | 
| Frequency of loose bowel movements? |  | 
| Problems with constipation? |  | 
| Ever have black tarry bowel movements? |  | 
| Excessive gas in your stomach? |  | 
| Ever had bright red bleeding from the rectum? |  | 
| Do you have pain with bowel movements? |  | 
©1999, Herbert A. Yates, D.O. and Neal R. Chamberlain, Ph.D.. All rights reserved.