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Gastroenterology Evaluation
Patient Name Patient DOB MRN
 
Data Reviewed:
ER Notes
Chart
Nursing Notes/Vitals log
Labs
Radiology data
ECHO
ECG
Stress Test
PFT
Care Coordinated with:
HCPOA
PCP
Case Mgmt or SW
Pharmacy 
Nursing
©MB and RR 2006-2008 Revised 26Feb08
Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
 
DateChief complaint/Reason for consult Referring MD
Start timeStop time
 
MedicationsHistory of Present Illness
Patient is Nonverbal. History obtained from
Family
Medical records 
Medications reviewed
Medications reconciled with Nursing Home or Hospital dischargeInformation
46Allergies
 
 Allergy List reviewed
 
No drug allergies
 
No food allergies
Nausea/Emesis
 Abdominal pain
Change in stool quality
Edema
Hematemesis
Dysphagia to
Solids
Liquids
Weight changes
Loss
Gain
H/O Heme + stool
Heartburn/Indigestion
Melena/Hematochezia
Rectal pain
Food intolerance
Water brash

 
Diarrhea
Jaundice
Fats
Nocturnal coughing or choking
Constipation
Increased abdominal girth
Wheat/Grains
Recent antibiotic use
Peritonitis
 Altered mental status
Prolonged INR
Social HistoryWNL Review of Systems
Never Smoker 
Tobacco ____ # Packs X ____ # Yrs
Quit

Patient is unwilling to quit
 

Patient willing to consider quitting

Patient quit, but resumed smoking
 

Patient willing to quit within 1 month
 
Daily, occasional and ex-smokers are morelikely to be hazardous drinkers
 Alcohol useDrinks per 
day
week
Hazardous drinking 
NIAAA (National Institute on Alcoholismand Alcohol Abuse guidelines)
Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day 
Recreational drug use

Inhalational 
Injectable
Ingestible
Drug dependence
Narcotics
 
Benzodiazepines
 
Constitutional
 
Fatigue
malaise
fever/chills
change in appetite
 
Eyes
Vision changes
New pain
Scotomas
 
ENT/mouth
 
Nose bleeds
dental caries
dental abscesses
 jaw pain
 
Resp
 
Dyspnea
Cough
Phlegm
Hemoptysis
Wheeze
 
CV
 
Chest pain
diaphoresis
 Ankle edema
PND
syncope
 
GI
 
See HPI 
 
 
GU
 
Change in urinary habits
Hematuria
Dysuria
 
Musc
 
Myalgias
Recent trauma
Bony fractures
 Arthralgias
Joint swelling
 
Skin/breasts
 
Rashes
Masses or skin lesions
Increased sensitivity to sun
 
Neuro
 
Seizures
Episodic or chronic muscle weakness
Headaches
 
Endo
 
Hair loss
Polydipsia
 
Heme/lymph
 
Bleeding gums
Unusual bruising
swollen lymph nodes
 
Allergy/Immun
 
Sinus probs
Recurrent infections
 
Psych
 
Mood changes
 Agitation
Psychosis
Delirium
Dementia
Additional Social History
Multiple sex partners
Tattoos
Rectal intercourse
Body piercings
Intercourse with commercial sex worker 
Vaccines
Hepatitis

Flu
Pneumo
BCG
Tetanus
Family Medical History Past Medical History Surgical History
Asthma
Congestive Heart Failure
COPD
Coronary Artery Disease
Diabetes
Familial Mediterranean Fever 
Hemochromatosis
Malignancy

 
Breast
 
 
Colon

Hepatic
 
Lung
 

Melanoma
 
Prostate
 

Testicular 
 
Thyroid

Other 
Pancreatitis
Peripheral Artery Disease
Renal Dysfunction
Thrombotic disorder 
Thyroid Disease
Achalasia
Peritonitis History of 
Antibiotic use
Cholecystitis
Polyps
Colectomy
Arteriovenous Malformations
Ischemic colitis
Sarcoidosis
Full
Partial
Autoimmune hepatitis
Hemochromatosis
Sclerosing cholangitis
Esophageal dilation
Barrett’s esophagus
Hemorrhoids
Sickle Cell Disease
Gastric bypass
Budd-Chiari Syndrome
Hepatitis
Thrombocytopenia
Gastric volume reduction
Carcinoid Syndrome
Hepatic dysfunction
Tuberculosis
Liver biopsy
C. difficile Colitis
Herpes
Ulcerative colitis
Malignant
Benign
Celiac Disease
Hernia
Ulcers
Pancreatic stent
Cirrhosis
Histiocytosis
VIPoma
PEG/PEJ tube
Colitis
HIV or AIDS
Whipple’s disease
Polypectomy
Crohn Disease
H. pylori positive
Wilson’s Disease
Malignant
Benign
Cystic Fibrosis
Inflammatory Bowel disease
Zollinger-Ellison Syndrome
Diverticulitis
Jaundice
Malignancy
TIPS
Diverticulosis
Liver disease
Breast
 
 
Colorectal
 
Other, specify
 
Esophageal Stricture
Malaria
Hepatic
 
Lung
Esophageal Varices
Nonalcoholic Fatty Liver Disease
Melanoma
 
Prostate
 
Familial Mediterranean Fever 
Parasitic infections
Testicular 
 
Thyroid
Cholelithiasis
 
Pancreatitis
Other 
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