GASTROINTESTINAL REPORT



PATIENT:_________________________________________________
SOCIAL SECURITY #:_______________________________________
DATE OF BIRTH:____________________________________________________

TO THE DOCTOR: Please complete the following report attaching copies of lab results
     for each condition. Please use the back of the form if additional space is needed.
1.Does this patient suffer from any gastrointestinal impairment or disease?
Yes _____ No ______. If yes:
 A.What is the current diagnosis?



 B.On what date was the diagnosis first made? _______________
 C.What is the date of onset, if different? _______________
 D.How long have you been treating the condition?



 E.What is the most recent date of examination?



 F.What was the patient's height _________ weight _________ at that time?



NOTE:If the diagnosis is chronic liver disease, diabetes mellitus or carcinoma, alternate forms will be provided. Do not complete this form unless there is an independent gastrointestinal impairment.

2.
Does the patient suffer from:
 A.Recurrent gastrointestinal hemorrhage? Yes _____ No ______
What is the cause of the hemorrhage?



 B.Is there esophageal disease? Yes ______ No ______
If so:
  1.Is there esophageal stricture? Yes ______ No ______
  2.Is there esophageal stenosis? Yes ______ No ______
  3.Is there esophageal obstruction? Yes ______ No ______
 
C.
Peptic Ulcer Disease? Yes _____ No ______?
If so, is there:
1.    recurrent ulceration?      Yes ______ No ______
2.  inoperable fistula?      Yes ______ No ______
3.  recurrent obstruction?      Yes ______ No ______
4.  perforation?      Yes ______ No ______
5.  recurrent hemorrhage?      Yes ______ No ______
 
D.
Chronic granulomatous or ulcerative colitis? Yes _____ No _____.
If so, is there recurrent bloody stool? Yes _____ No _____
 
E.
Regional enteritis? Yes _____ No _____.
If so, is there:
1.    persistent or recurrent
intestinal obstruction          		Yes ______ No ______
2.  abdomianl pain      Yes ______ No ______
3.  abdominal distention      Yes ______ No ______
4.  nausea      Yes ______ No ______
5.  vomiting      Yes ______ No ______
6.  stenotic areas of small
bowel with proximal
intestinal dilation      		Yes ______ No ______
 
F.
Pancreatitis? Yes _____ No ______. If so, what is the etiology?



 G.Gastritis? Yes ______ No ______. What is the etiology?



3.What diagnostic procedures have you performed?

A.    
x-ray          
Yes ______
No ______
Date ______
B.    endoscopy          Yes ______ No ______Date ______
C.    barium studies          Yes ______ No ______Date ______
D.    biopsy          Yes ______ No ______Date ______
E.    surgery          Yes ______ No ______Date ______

4.
If surgery has been performed, describe the procedure and results:



Have any symptoms recurred after surgery? Yes _____ No ______.
If so, why?


5.
Has surgery been recommended or prescribed? Yes ______ No ______
If so, why?




6.
Have any of the following laboratory tests been performed? If so, please list test results and dates:
 TESTRESULTDATE(S)
A.Serum amylase concentration      _____________    ____________
B.Amylase/creatinine clearance ratio      _____________    ____________
C.serum triglyceride      _____________    ____________
D.serum lipase      _____________    ____________
E.serum bilirubin      _____________    ____________
F.serum calcium      _____________    ____________
G.parahormone concentration      _____________    ____________
H.thyrocalcitonin concentration      _____________    ____________
I.lastic dehydrogenase concentration      _____________    ____________
J.serum aspartate transferase (SGOT)      _____________    ____________
K.pao2      _____________    ____________

What are three recent hematocrit readings?
  _____________    _____________
  _____________    _____________
  _____________    _____________

7.
Has there been weight loss due to any gastrointestinal disorder? If so,

A.    
has the weight loss persisted
for more than three months?          
Yes ______
No ______
B.    is it expected to persist for a
total of 12 or more months?          
Yes ______
No ______

8.
Does the patient experience malabsorption? Yes ______ No ______
If so, what are the last 3 lab readings for:
 TESTRESULTDATE(S)
A.serum albumin                _____________    ____________
B.serum calcium      _____________    ____________
C.fat in stool      _____________    ____________
D.nitrogen in stool      _____________    ____________
9.Does the patient suffer from:

A.    
dumping syndrome          
Yes ______
No ______
B.    anemia          Yes ______ No ______
    If so, what type: ___________________________
C.    vitamin deficiency          Yes ______ No ______
    If so, what vitamin: _________________________
10.Are there persistent or systemic manifestations, such as:

A.    
arthritis          
Yes ______
No ______
B.    iritis          Yes ______ No ______
C.    fever          Yes ______ No ______
D.    liver disfunction          Yes ______ No ______
E.    intractable abscess          Yes ______ No ______
F.    fistula formation          Yes ______ No ______
G.    stenosis          Yes ______ No ______

11.
Please indicate which, if any of the following symptoms related to gastrointestinal disorder has been reported by the patient and is consistent with the diagnosis.
 A.   ________ weakness
B.   ________ fatigue
C.   ________ dizziness
D.   ________ diarrhea
E.   ________ nausea
F.   ________ vomiting
G.   ________ fecal incontinence
H.   ________ dysphagia
I.   ________ pain
J.   ________ constipation

12.
What is the present therapy for the condition?




13.
What has been the response to treatment?




14.
What medications are the patient currently taking for the condition?




15.
Are there any observed or reported side effects from the medication? Yes _____ No ______
If so, what are they:




16.
What restrictions of life style or daily living have been recommended?




17.
From what other medical or psychological conditions does the patient suffer in addition to those described above?



Are you treating these conditions?



Date Report Completed: ______________________________
Signature of Physician: ______________________________
Physician Name: ______________________________
Address: ______________________________
Telephone: ______________________________
Specialty: ______________________________

Law Office Of:
Jerrold S. Zivic
850 W. Jackson Blvd.
Suite 405
Chicago, IL 60607
800-400-4357