GI First Visit Questionnaire Form

  • GI First Visit Questionnaire Form

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Date of your appointment with Dr. Fuchs
     - -
  • Did you see any other doctor for this issue?
  • Have you had any tests for this issue?
  • Do you/have you taken any medications for this issue?
  • Personal Medical History - Check all that apply:

  • Surgical History

  • Recent Hospitalizations
  • Have you ever had a colonoscopy or endoscopy in the past?
  • Approximate date of colonoscopy/endoscopy
     - -
  • Rows
  • Rows

  • Review of Systems - Please check any persistent or recurring symptoms:

  • Should be Empty: