Medical History - Basics | Michael W Goodman MD PC

(423) 267-5677
info@goodman-gi.com
Mon - Fri: 9:00 - 5:00

Our Providers
- Dr. Michael Goodman
- Caitlin Grant Collier, FNP
Treatment Info
Patient Forms
FAQs
- General FAQ
- Billing FAQ

Our Providers
- Dr. Michael Goodman
- Caitlin Grant Collier, FNP
Treatment Info
Patient Forms
FAQs
- General FAQ
- Billing FAQ

Medical Assessment - Basics
(Form 1 of 6)

Name

Date of Birth

Form Entry Date

Referred By

Referred For

PCP (if not referring physician)

Other M.D.'s

Occupation

Do you have a family member that is seen by this office?

Yes No

If Yes, who?

Are you experiencing any of the following symptoms? (Please check)

Persistent cough (One which has lasted for 3 or more weeks) Bloody Sputum Night Sweats Weight loss Anorexia Fever

Are you experiencing any of the following upper GI symptoms? (Please check)

Painful swallowing Vomiting blood Indigestion Excessive belching Food sticking Reflux Abdominal pain Nausea Heartburn Weight loss Vomiting Loss of appetite Early satiety (fill up too quickly)

Are you experiencing any of the following lower GI symptoms? (Please check)

Diarrhea Black, tarry stool Rectal pain Constipation Urgency Incontinence (soiling) Red blood in stool Hemorrhoids Gas/bloating Straining Rectal prolapse

Number of bowel movements per day

Number of bowel movements per week

Bowel movements are (please check)

Hard Soft Formed Loose Watery Marble-like

Do you see pus or mucous in stool?

Yes No

Daily tobacco use: Current

Past History

(Packs/how much snuff/chewing tobacco/cigars per day)

Alcohol use: Current

Past History

(drinks per day/week)

Daily caffeine use: Current

Past History

(cups or glasses of Coke, coffee or tea a day)

Dairy products: Current

Past History

(how many servings per day)

Herbal remedies: Current

Past History

(how much/how many times a day or week)

Illegal Drug Use: Current

Past History

(drugs used)

Are you pregnant?

Yes No

Are you nursing?

Yes No

Our Location

Erlanger Medical Mall
979 East Third Street
Suite C-0630
Chattanooga, TN 37403
423.267.5677

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More Info

If you need additional information, please call us at (423) 267-5677, or send an e-mail to info@goodman-gi.com.

Current Patients - Access our Patient Portal

Medical Assessment - Basics(Form 1 of 6)

Our Location

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More Info

Medical Assessment - Basics
(Form 1 of 6)