Year 1 Medical History Questionnaire
Personal Medical History
Section 3: Review of Systems
Please indicate whether you have had a significant problem with any of the symptoms or conditions listed below. If it is a problem that has happened more than once, mark "recurring" as well as all ranges of years in which it happened.
23. GASTROINTESTINAL
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Fatty food intolerance
Ulcer, gastric
Ulcer, duodenal
Ulcer, location unknown
Frequent heartburn
Vomited blood
Gallbladder trouble
Gallbladder removed
Abdominal pain
Jaundice or cirrhosis
Frequent diarrhea
Diarrhea caused by milk (lactose intolerance)
Part of intestines removed
Pancreatitis
Ulcerative colitis or Crohn's disease
Blood in stools
Hemorrhoids
Colon polyps
Chronic constipation
Appendicitis
Appendix removed
Cancer of colon or rectum