Symptomskjema før time til gastroenterolog

02.01.2015

For nye pasienter:

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

Aktuell problemstilling:

I. Symptomer:

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II. Debut og varighet av symptomer:

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III. Symptomer tilstede om natt?

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IV. Symptomer etter matinntak?

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V. Vekttap?

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VI. Appetitt:

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VII. Avføring:

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VIII. Annen utredning som er utført (blodprøver, ultralyd/CT, mm.):

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IX. Tidligere sykdommer, gjennomgåtte operasjoner:

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X. Sykdommer i slekt:

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XI. Bruk av NSAIDS (betennelsesdempende medisiner som for eksempel

Ibux, Voltaren, Naproxen, Brexidol, Arthrotec med flere):

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XII. Faste medisiner:

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XIII. Allergier:

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XIV. Forbruk av sigaretter/snus:

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XV. Alkoholforbruk:

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XVI. Yrke:

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XVII. Fastlege (navn eller legesenter):__________________________________________