Gastroenterology Intake Form

The Gastroenterology Intake Form is tailored for GI practices and hepatology clinics, collecting the detailed digestive history that gastroenterologists need for efficient patient evaluation. This template captures patient demographics alongside a comprehensive GI symptom assessment covering abdominal pain (location, character, timing, aggravating and relieving factors), nausea and vomiting, dysphagia, heartburn and reflux, bloating, changes in bowel habits, rectal bleeding, unintentional weight loss, and jaundice. The structured symptom timeline helps providers distinguish acute presentations from chronic conditions.

Designed for general gastroenterology, hepatology, inflammatory bowel disease, and motility clinics, this form includes sections for prior GI procedures (EGD, colonoscopy, ERCP, capsule endoscopy, liver biopsy), relevant surgical history (cholecystectomy, appendectomy, bariatric surgery), family history of GI cancers and inflammatory bowel disease, and a thorough medication review including PPIs, H2 blockers, biologics, immunomodulators, and laxatives. The dietary and lifestyle section captures alcohol intake, tobacco use, and dietary patterns relevant to GI conditions.

All fields are HIPAA-compliant and structured to support the gastroenterology workflow from initial consultation through procedure scheduling. The form helps patients organize their GI history before the appointment, ensuring that critical details about symptom onset, progression, and prior workup are documented accurately. Providers can review the completed form to prioritize diagnostic testing and determine whether endoscopic evaluation is indicated.