SYMPTOMSKJEMA FØR TIME TIL GASTROENTEROLOG

For nye pasienter.
Det er til hjelp for legen hvis du på forhånd har fylt ut følgende opplysninger (hvis relevant): 

Aktuell problemstilling: 
•	Symptomer: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
•	Debut og varighet av symptomer: ________________________________________________________________________________________________________________________________________________________
•	Symptomer tilstede om natt? ________________________________________________________________________________________________________________________________________________________
•	Symptomer etter matinntak? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
•	Vekttap? ________________________________________________________________________________________________________________________________________________________
•	Appetitt: ________________________________________________________________________________________________________________________________________________________
•	Avføring: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
•	Annen utredning som er utført (blodprøver, ultralyd/CT, mm.): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
•	Tidligere sykdommer, gjennomgåtte operasjoner: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
•	Sykdommer i slekt: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
•	Fast regelmessig bruk av NSAIDS (betennelsesdempende medisiner som for eksempel Ibux, Voltaren, Naproxen, Brexidol, Arthrotec med flere): ________________________________________________________________________________________________________________________________________________________
•	Andre faste medisiner: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
•	Allergier: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
•	Forbruk  av sigaretter/snus: ________________________________________________________________________________________________________________________________________________________
•	Alkoholforbruk: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
•	Yrke: ________________________________________________________________________________________________________________________________________________________
•	Navn på fastlege/ epikrisemottaker (ved behov) 
________________________________________________________________________________________________________________________________________________________
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