Intestines (Large and Small)

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Weight gain or loss.
2. Nausea and/or vomiting.
3. Constipation, diarrhea (frequency, severity, duration, and episodic or not?).
4. For fistula - frequency, duration, and amount of fecal discharge.
5. Treatment - type, duration, response, side effects.
6. Abdominal pain, distress, cramps - frequency, duration, location.
7. For ulcerative colitis - number of attacks per year.
8. Effects of condition on occupational functioning and activities of daily living.
9. History of trauma.
10. History of hospitalizations or surgery - reason or type of surgery, location and dates, if known.
11. History of neoplasm:

1. Date of diagnosis, diagnosis.
2. Benign or malignant.
3. Treatment, dates and response.
4. Last date of treatment.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Malnutrition, other evidence of debility.
2. Abdominal pain - location.
3. For fistula - location, presence of discharge.
4. Ostomy present- type.
5. Abdominal mass.
6. Signs of anemia.
7. Weight - gain or loss.

D. Diagnostic and Clinical Tests:

1. If signs of anemia, obtain hemoglobin/hematocrit.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: