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? 
Food that smells bad.
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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©1998,  Neal R. Chamberlain, Ph.D.. All rights reserved.