• GI First Visit Questionnaire Form

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of your appointment with Dr. Fuchs
     - -
    2 digit month, 2 digit day, 4 digit year
  • Did you see any other doctor for this issue?
  • Please list the doctors seen for this issue
  • Have you had any tests for this issue?
  • Please list the test performed for this issue
  • Do you/have you taken any medications for this issue?
  • Personal Medical History - Check all that apply:

  • Surgical History

  • List any surgeries you have had and the year they were performed:
  • Recent Hospitalizations
  • List Hospital
  • Please list your current medications
  • Have you ever had a colonoscopy or endoscopy in the past?
  • Approximate date of colonoscopy/endoscopy
     - -
    2 digit month, 2 digit day, 4 digit year
  • Social History
    Rows
  • Family History - Check all that apply and specify relationship:
    Rows

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

  • Gastrointestinal
  • General
  • ENT
  • Respiratory
  • Cardiovascular
  • Skin
  • Neurologic
  • Hematologic
  • Psych
  • Genitourinary
  • Musculoskeletal
  • Should be Empty: