GI Map Patient Information and Medical History Form

GI Map Patient Information and Medical History Form

Please complete form thoroughly as information is needed for personalized GI MAP protocol
Today's Date*

MonthDayYear
Date of Birth*

MonthDayYear
Full Name*

First NameLast Name
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
How were you referred to this office?*
What is your gender?*
Cell Phone Number*
Physicians/Providers
Primary Care Physician (PCP)*
PCP Phone Number*
Please enter a valid phone number.
Gastroenterologist (current, previous or N/A)*
Medical History

Hospitalizations, Surgeries, Procedures, Transplants and/or Injuries*

	Type	Description	Date (MM/DD/YYYY)
#1
#2
*3
#4

Medications, Supplements, Antibiotics*

	Medication/Supplement/Antibiotic Name	Reason you take	Date Began (MM/DD/YYYY)	Dose
#1
#2
#3
#4
#5
#6

Allergies and Reactions*

	Allergy	Reaction
#1
#2
#3
#4

Medical Conditions
Check the medical conditions that apply to you:*

Alcoholism or Substance AbuseDigestive (Ulcerative Colitis, Crohn's Disease, etc.)High CholesterolArthritis/Joint DiseaseEating DisordersAIDS/HIVAllergies/Sensitivities (Medicines, Skin, Food) (Specify below)Fatty LiverLIver DiseaseAnxietyFrequent InfectionsLung Disease (Asthma, COPD)Autoimmune ConditionsHeadaches/MigrainesOsteoporosis/OsteopeniaBlood Clot/PhlebitisHeart AttackPsychiatric DisorderBlood Disorders (Specify below)Heart DiseasePulmonary EmbolismCancer (Specify below)Heart FailureStrokeCirrhosisHemochromatosisThyroid Disease (Specify below)DepressionHepatitis (Specify below)Urinary difficulties (Incontinence, infections, etc.)DiabetesHigh Blood PressureOther (Specify below)
Medical Symptoms

Check each of the following symptoms you are currently experiencing
Head*

Headache or MigrainesFaintnessDizzinessInsomniaN/A
Eyes*

Watery or itchy eyesSwollen, reddened, or sticky eyelidsBags or dark circles under eyesBlurred or tunnel vision (doesn't include nearsightedness or farsightednessN/A
Nose*

Stuffy noseSinus problemsHay feverSneezing attacksExcessive mucus formationN/A
Weight*

Binge eating or drinkingCraving certain foodsExcessive WeightCompulsive eatingWater retentionUnderweightInability to lose weightN/A
Mind*

Poor memoryConfusion, poor comprehensionPoor concentrationPoor physical coordinationDifficulty in making decisionsStuttering or stammeringSlurred speachLearning disabilitiesN/A
Skin*

AcneHives, rashes, dry skinHair lossFlushing, hot flashesNight sweatsExcessive sweatingCold all the timeDry and wrinkled skinN/A
Heart*

Irregular or skipped heartbeatRapid or pounding heartbeatChest painN/A
Emotions*

Mood swingsAnxiety, fear, nervousnessAnger, irritability, aggressivenessDepressionN/A
Lungs*

Chest congestionAsthma, bronchitisShortness of breathDifficulty breathingN/A
Digestive Tract*

Nausea, vomitingDiarrheaConstipationBloated feelingBelching, passing gasHeartburnIntestinal or stomach painN/A
Joints and Muscles*

Pain or aches in jointsArthritisStiffness or limitation of movementPain or aches in musclesFeeling of weakness or tirednessN/A
Ears*

Frequent illnessFrequent or urgent urinationLoss of urine/incontinenceGenital itch or dischargeN/A
Male Sexual Health*

Decreased sex drive/low libidoDifficult to climax sexuallyDecreased morning erectionsInfrequent or absent ejaculationsNo results from ED medicationsN/A
Female Sexual Health*

Decrease sex drive/low libidoDifficult to climax sexuallyVaginal laxityVaginal drynessN/A
List the symptoms you are most concerned about.*
Digestive History
Check the digestive history that apply to you:*

Chronic and Acute GastroenteritisViral InfectionsInflammatory Bowel DiseaseAcid Reflux Medication UseIrritable Bowel SyndromeNSAID (Ibuprofen) UseSmall Intestine Bacterial Overgrowth (SIBO)Food Sensitivities (If yes, explain below)Suspected H. Pylori Infection / Stomach UlcersRosaceaFungal or Yeast InfectionsRecurrent Urinary Tract Infections (UTIs)Bacterial and Parasitic InfectionsRecent Food PoisoningOther (Specify below)N/a
Specify from above (if necessary) and approximate start date if any of the above apply.*
Have you had any testing for your digestive system to this point?*

YesNo
Women's Health
Current or Past Birth Control Use*
Birth Control Type*
How long did you use (years)?*
Preventative Health
Colonoscopy*
Date of Colonoscopy

MonthDayYear
Cologuard*
Date of Cologuard

MonthDayYear
Endoscopy*
Date of Endoscopy

MonthDayYear
Social Habits and Lifestyle
Tobacco Use:*

NeverCurrentlyIn the Past
How many cigarettes per day?*
How many years of tobacco use?*
Alcohol Use:*

NeverCurrentlyIn the Past
How many drinks per day?*
How many drinks per month?*
Have you had any recent travel outside your current country?*

YesNo
If yes, where?*
Sleep and Relaxation
Emotional Stress Scale*

1

2

3

4

5

6

7

8

9

10

1 is Low Stress, 10 is High Stress
How many hours do you usually sleep per night?*
Exercise and Nutrition
Height*
Present Weight*
Desired Weight*
Do you exercise regulary*

YesNo
Describe your exercise regimen*
How many glasses of water do you drink daily?*
Are you currently on a special diet?*

YesNo
Do you currently eat gluten?*

YesNo
Describe your diet?*
Do you feel certain foods affect your digestive system in a negative way? If so, which foods?*
How often do you have a bowel movement?*
Commitment Level to making a change in your life today (1 = less committed; 10 = most committed)*

1

2

3

4

5

6

7

8

9

10

1 is Low Commitment, 10 is High Commitment
What is your goal by doing the GI Map test and protocol for gut healing?*
Signature*

Clear
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GI Map Patient Information and Medical History Form

Physicians/Providers

Medical History

Medical Conditions

Medical Symptoms

Digestive History

Women's Health

Preventative Health

Social Habits and Lifestyle

Sleep and Relaxation

Exercise and Nutrition