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info@goodman-gi.com
Mon - Fri: 9:00 - 5:00
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Our Providers
Dr. Michael Goodman
Caitlin Grant Collier, FNP
Treatment Info
Common GI Diseases and Disorders
Preps and Procedures
Understanding Colonoscopies
Infliximab Treatment for Crohn’s & Colitis
In-Office Endoscopy Suite
Patient Forms
Patient Bill of Rights
Patient Packet
Patient Satisfaction Survey
FAQs
General FAQ
Billing FAQ
Our Providers
Dr. Michael Goodman
Caitlin Grant Collier, FNP
Treatment Info
Common GI Diseases and Disorders
Preps and Procedures
Understanding Colonoscopies
Infliximab Treatment for Crohn’s & Colitis
In-Office Endoscopy Suite
Patient Forms
Patient Bill of Rights
Patient Packet
Patient Satisfaction Survey
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
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