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Gastroenterology Evaluation Patient Name Patient DOB MRN

Date Chief complaint/Reason for consult Referring MD


Start time
Stop time
Medications History of Present Illness ‰Patient is Nonverbal. History obtained from ‰ Family ‰ Medical records
‰Medications reviewed 

‰Medications reconciled with Nursing

Home or Hospital discharge 
Information œ46 



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

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 œIndicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Gastroenterology Evaluation Patient Name Patient DOB MRN
Prior Diagnostic Data Exam

General ‰Alert Vitals T P R BP Sats %


\____/
/ \ ENT ‰TM ‰Pharynx ‰Dentition ‰ Nasal ‰External ears ‰ Hearing
Neck ‰ Exam ‰ Thyroid
____ / ____ / ____ / Resp ‰ Clear to auscultation ‰ Clear to percussion ‰Effort ‰Normal to palpation
\ \ \ CV ‰ Auscultation ‰ Palpation ‰ Edema ‰Carotids ‰ Aorta ‰Femoral pulses ‰ Pedal pulses
GI ‰ Abdomen ‰ No hepatosplenomegaly ‰ No hernias ‰ Rectum ‰ Guaiac
Lymph ‰ Neck ‰ Axilla ‰ Groin ‰ Other
Musc ‰ Gait ‰ Digit ‰ Inspection ‰ ROM ‰ Stability ‰ Strength
Skin ‰ Inspection ‰ Palpation
Neuro ‰ CN ‰www.e-medtools.com
DTR ‰ Sensation
Psych ‰ Affect ‰ Orientation ‰ Insight ‰ Memory
Glasgow Coma Score E____ V____ M____ APACHE II Score ____
Plan Impression
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‰ABG ‰ Patient has completed advanced health care directivesœ47 HCPOA is
‰CBC
Code Status ‰ Patient is a FULL CODE ‰ DO NOT ATTEMPT RESUSCITATION
‰PT, PTT, INR
‰BMP
‰CMP
‰AST, ALT, Alkaline Phosphatase
‰Bilirubin, direct and indirect www.e-medtools.com
Serum levels
‰Albumin
‰Alpha-fetoprotein
‰Amylase
‰Ceruloplasmin www.e-medtools.com
‰Iron, ferritin
‰Lactate
‰Lipase

‰Hepatitis Panel
‰HIV
‰ANA www.e-medtools.com
‰ANCA
‰Anti-LKM1
‰Anti-SLA/LP
‰CA 19-9
‰Carcinoembryonic antigen (CEA) www.e-medtools.com

‰Blood and Urine drug/tox screen
‰Blood alcohol level
‰Acetaminophen level
‰ASA level

‰Blood cultures
‰Blood type and screen

‰CT of abdomen and pelvis
‰CT colonography
‰MRI of liver
‰MRCP
‰Barium esophagram
‰Barium enema
‰Upper GI series
(small bowel follow through)
‰RUQ Ultrasound
‰HIDA scan
‰Endoscopy Follow Up Signature
‰ERCP cc
‰Paracentesis

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 œIndicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures

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