Elias Fanous, Jr., M.D., P.A.  F/U Sheet
                                                                                           (copyright pending)
Your name:__________________________ Today's date:_____/________/______________
Your phone #_________________________ Main reason you're here:___________________
Your email:__________________________ How long has it bothered you?_______________
Date of birth: ___/____/___ Your age______ Who is your primary doctor?_________________
Preferred Pharmacy:___________________ Who sent you to see us?____________________
Please list each medication you take, include the dosage and how long you have been taking them:
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Circle "yes" or "no" to every question Circle "yes" or "no" to every question
Dysphagia Abdominal Pain
Food sticks when I swallow yes no My stomach often hurts yes no
If yes, how many times per week?______ Circle how severe:None 1 2 3 4 5 6 7 8 9 10 (very severe)
I sometimes retch/vomit to free solid food yes no If yes, how many times per week?___________
Water often sticks when I swallow yes no Is it sharp/burning or dull/aching/pressure (circle one)
I often have pain with swallowing yes no Is it constant or off&on? (circle one)
Reflux Does it travel to your back? yes no
Do you have reflux despite medication? yes no Does it wake you from sleep? yes no
If yes, how many times per week?______ Does it ever last more than one hour? yes no
Acid/sour/bitter/burning in or up chest yes no Is it better or worse with food? (circle one) yes no
Easily relieved with antacids yes no What makes it better?_____________________
Are you on prescription acid medication? yes no What makes it worse?_____________________
If yes circle one: nexium  prevacid  aciphex   Colon
zegerid  pantoprazole  prilosec omeprazole Have you ever had colon polyps? yes no
Has your heart been evaulated recently yes no Last time you had colonoscopy:_____________
Nausea/Vomiting Colon polyps/cancer in any blood relative? yes no
I often have nausea (queasy)  yes no If yes, circle: brother  sister   mom   dad   child
If yes, how many times per week?______                aunt/uncle      cousin       grandparent
Is it better or worse with food (circle one) yes no Do you have diverticulosis or diverticulitis yes no
My nausea is caused by my medicines yes no Bowel Changes
My nausea has no rhyme or reason yes no Often constipated (#days without bm:________) yes no
Do you vomit? yes no I often have diarrhea (times per day:____) yes no
If yes, how many times per week?______ I take laxatives (times per week:_______) yes no
I vomit liquid only yes no I have seen blood in my stool yes no
I vomit undigested or digested food yes no My stool has been black or tarry yes no
Dyspepsia I take iron or pepto bismol (if yes, circle which) yes no
I often have bothersome gas/belching yes no Blood on the toilet paper or in the bowl (circle) yes no
I have bloating/distension that is NEW yes no Bowels move urgently after eating yes no
I recently feel full with only a few bites yes no #BMs per day:_____  #BMs per week________
Constitutional Symptoms/Liver My stool has changed in shape or caliber yes no
Are you losing weight? yes no Do you soil yourself? yes no
Are you dieting or trying to lose weight? yes no Do you smoke? yes no
I often have fever over 100 degrees yes no Do you drink beer, wine or liquor? yes no
How much weight lost in 3 months?:_____ _________________________________________________
I currently have hepatitis B or C (circle) yes no _________________________________________________
If on treatment, how many weeks?_______ _________________________________________________