Pg1/3                                Elias Fanous, Jr., M.D., P.A.  
                                                                                           (copyright pending pg1-3)
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?_________________
Current/Past occupation:_______________ Who sent you to see us?____________________
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?______ If yes, how many times per week?___________
I sometimes retch/vomit to free solid food yes no Is it mainly sharp or dull/aching? (circle one) yes no
Water often sticks when I swallow yes no Is it pressure-like or burning? (circle one) yes no
I often have pain with swallowing yes no Is it constant or off&on? (circle one) yes no
Reflux Does it travel to your back? yes no
Do you have reflux 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   Dyspepsia
zegerid  pantoprazole  prilosec omeprazole I often have bothersome gas yes no
Chest Pain I have bloating/distension that is NEW yes no
Are you here because of chest pain? yes no I have belching/burping that is NEW yes no
If yes, how many times per week?______ I recently feel full with only a few bites yes no
Is it dull or sharp (circle one) yes no Colon
Is it burning or pressure-like (circle one) yes no Have you ever had colon polyps? yes no
Is is worse with food? yes no Last time you had colonoscopy:_____________
Does it go from your chest to your back? yes no Colon cancer in any blood relative? yes no
Has your heart been evaulated recently yes no Colon polyps in any blood relative? yes no
Nausea/Vomiting If yes, circle: brother  sister   mom   dad   child
I often have nausea (queasy)  yes no                aunt/uncle      cousin       grandparent
If yes, how many times per week?______ Do you have diverticulosis or diverticulitis yes no
Is it better or worse with food (circle one) yes no Bowel Changes yes no
My nausea is caused by my medicines yes no Often constipated (#days without bm:________) yes no
My nausea has no rhyme or reason yes no I often have diarrhea (times per day:____) yes no
Do you vomit? yes no I take laxatives (times per week:_______) yes no
If yes, how many times per week?______ I have seen blood in my stool yes no
I vomit liquid only yes no My stool has been black or tarry yes no
I vomit undigested or digested food yes no I take iron or pepto bismol (if yes, circle which) yes no
Ulcers Blood on the toilet paper or in the bowl (circle) yes no
I have had a stomach ulcer before yes no Bowels move urgently after eating yes no
A doctor looked in my stomach with light yes no #BMs per day:_____  #BMs per week________
I was treated for a bacteria called H pylori  yes no My stool has changed in shape or caliber yes no
Constitutional Symptoms Do you soil yourself? yes no
Are you losing weight? yes no Liver yes no
Are you dieting or trying to lose weight? yes no I currently have hepatitis B or C  (circle) yes no
I often have fever over 100 degrees yes no Do you have a tattoo? yes no
How much weight lost in 3 months?:_____ Ever had blood transfusion?What year?_______ yes no