Pre-Registration    Medical History

* - denotes required fields
*Name:
*Email:
Esophageal Reflux/GERD?
Ulcer Disease/Gastritis?
Gallstones?
Hepatitis/Cirrhosis/Liver Disease?
Pancreatitis?
Irritable Bowel Syndrome?
Crohn's Disease/IDB?
Lactose Intolerance?
Celiac Sprue?
Other Food Allergy?
Colorectal Cancer/Polyps?
Hemorrhoids?
Other Cancer?
Diabetes?
Hypertension?
Heart Disease?
Lung Disease?
Kidney Disease?
Endocrine Disease(thyroid, adrenal, etc)
Current Smoker?
Previous Smoker?
Alcohol Use?
Drug Allergies?
  List all Significant hospitalizations and surgeries including dates:
 
  List all current medications and dosages:
 
  List all vitamins, supplements and dosages:
 
 
System Assessment
 
Loss of Appetite Unexplained Weight Loss
Nausea Vomiting
Pain with Swallowing Food sticking in Esophagus
Heartburn Excessive Belching
Pain beneath Breastbone or Right Ribs after eating Jaundice
Severe Abdominal Cramps Sustained Abdominal Distension after Eating
Diarrhea Black Stool
Blood in Stool Excessive Flatus
Foul-Smelling Stools
 
Prior Upper Endoscopy:
/ /
Location:
Prior Upper GI Xray:
/ /
Location:
Prior Small Bowel Xray:
/ /
Location:
Prior Flexible Sigmoidoscopy:
/ /
Location:
Prior Colonoscopy:
/ /
Location:
Prior Lower GI Xray:
/ /
Location:


Digestique
676 North St. Clair
Suite 1525,
Chicago, IL 60611
312-695-9393
Fax 312-695-2275

Hours:
Monday - Friday
9am - 5pm

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