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Please select Medical Service:
Intake - IBS
Intake - GERD
Intake - Migraine/Headaches
First Name:
Last Name:
Email:
Phone:
What is your current rating?
N/A
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Please list down all CURRENT Disability/ies and rating/s for each. (Write N/A if you do not have any current disability rating. Eg PTSD 70%, Sleep Apnea 50%)
Have you ever been diagnosed with the condition you are being prescreened for? If yes, please explain in the box provided below.
Yes
No
In the last 3 months, how often did you have discomfort or pain anywhere in your abdomen?
All of the time
Most of the time
Some of the time
Never
Have you experienced this discomfort or pain for 6 months or longer?
Yes
No
For women only: Did this discomfort / pain occur only during menstruation and not at other times?
Yes
No
How often did this discomfort / pain improve or stop after you had a bowel movement?
All of the time
Most of the time
Some of the time
Never
After this discomfort / pain started, did you experience more frequent bowel movements?
All of the time
Most of the time
Some of the time
Never
After this discomfort / pain started, did you have less frequent bowel movements?
All of the time
Most of the time
Some of the time
Never
After this discomfort / pain started, were your bowel movements looser?
All of the time
Most of the time
Some of the time
Never
After this discomfort / pain started, how often did you have harder stools?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you produce hard or lumpy stools?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you produce loose or watery stools?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you experience difficulty having a bowel movement (straining, feeling that you have not finished)?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you feel you had to rush to the bathroom as soon as you noticed the urge to have a bowel movement?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you feel bloated?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you feel that your abdomen was actually visibly distended?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you feel uncomfortable due to a problem with passing lots of gas?
All of the time
Most of the time
Some of the time
Never
Are any of the following diseases present in your family? - Colon cancer - Celiac disease - Inflammatory bowel disease (Ulcerative colitis, Crohn's disease)
Yes
No
Have you experienced unintentional weight loss over the past 3 months?
Yes
No
Over the past 3 months did you see blood in the toilet with your stool?
All of the time
Most of the time
Some of the time
Never
Did your symptoms wake you up at night over the past 3 months?
All of the time
Most of the time
Some of the time
Never
Were you recently treated with antibiotics?
Yes
No
First Name:
Last Name:
Email:
Phone:
What is your current rating?
N/A
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Please list down all CURRENT Disability/ies and rating/s for each. (Write N/A if you do not have any current disability rating. Eg PTSD 70%, Sleep Apnea 50%)
Please list any medication, prescription, and over-the-counter medicine that you take FOR ANY OF YOUR SERVICE CONNECTED DIABILITIES.
Have you ever been diagnosed with the condition you are being prescreened for? If yes, please explain in the box provided below.
Yes
No
Which of the following best describes your main complaint?
Burning sensation in your upper abdomen / stomach
Burning sensation in your chest and throat
Nausea or vomiting
Pain in the middle of your chest when you eat
Other
Which of the following best describes the timing of your complaint?
Any time. There is no relation to eating
Within the first 2 hours after eating
Always occurs at the same time of the day or night with no relation to eating
Other
You eat much more than you're accustomed to?
Worse
Better
Nothing happens
You eat fatty foods?
Worse
Better
Nothing happens
You eat spicy or highly seasoned foods?
Worse
Better
Nothing happens
What happens to your symptoms after you take antacids?
Nothing
Complete relief within the first 15 minutes
Complete relief after about 15 minutes
I don't take antacids
What happens to your symptoms when you bend over or lie down?
Nothing
They get worse
They get better
Which of the following best describes the effect that carrying heavy objects, straining or performing strenuous exercise has on your symptoms?
No effect
They get worse
They get better
If you regurgitate the contents of your stomach into your throat or mouth, what happens insofar as your main complaint is concerned?
Nothing
It gets worse
Regurgitation is what causes my main complaint
It gets better
I don't regurgitate
Over the past week, how many days have you experienced a burning sensation in your chest?
Never
1 day
2-3 days
4-7 days
Over the past week, how many days have you been bothered by the contents of your stomach coming up into your throat or mouth?
Never
1 day
2-3 days
4-7 days
Over the past week, how many days have you experienced pain in your upper abdomen / stomach?
Never
1 day
2-3 days
4-7 days
Over the past week, how many days have you been nauseated or felt like vomiting?
Never
1 day
2-3 days
4-7 days
Over the past week, how many nights have you had difficulty sleeping because of burning pain in your chest or because the contents of your stomach have come up into your throat or mouth?
Never
1 day
2-3 days
4-7 days
Over the past week, how many days have you taken any type of medication or home remedy for burning pain in your chest or because the contents of your stomach have come up into your throat or mouth?
Never
1 day
2-3 days
4-7 days
First Name:
Last Name:
Email:
Phone:
What is your current rating?
N/A
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Please list down all CURRENT Disability/ies and rating/s for each. (Write N/A if you do not have any current disability rating. Eg PTSD 70%, Sleep Apnea 50%)
Have you ever been diagnosed with the condition you are being prescreened for? If yes, please explain in the box provided below.
Yes
No
What year did your headaches begin?
How old were you at the time?
How many prostrating headaches do you experience each month?
How long do they last?
On a scale of 0-10, on average, how painful are your headaches? (10 being the highest)
0
1
2
3
4
5
6
7
8
9
10
Please briefly describe how these headaches affect your job and family life.
Do you have more than one type of headache?
Yes
No
In your opinion, which of the following triggers your headaches?
Hormonal changes
Stress
Exercise
Relaxation after stress
Change in weather
Bright light / glare
Loud noise
Odors / smoke
Lack of sleep
Too much sleep
Hunger
Alcohol
Certain foods or food additives
Other
Do you get any other symptoms along with your headaches?
Neck pain
Worsening of pain with movement
Nausea / vomiting
Dizziness
Light sensitivity
Numbness
Noise sensitivity
Weakness
Tearing
Confusion
Nasal congestion
Difficulty speaking
Eyelid dropping
Other
What type of actions have you taken to help your headaches?
Rest in a quiet, dark room
Ingest Caffeine
Hot or cold compresses to your head or neck
Take over-the-counter medications
Massage
Other
Are there some days when you are completely free of pain? Describe the pain:
Throbbing
Sharp / stabbing / electric
Pulsating
Pressurized / vise-like compression
Dull aching
Exploding outward
Other
When you have a headache does your scalp and face become sensitive to touch such that you avoid putting on glasses or combing your hair?
Yes
No
What warning signs, if any, do you develop before the start of a headache?
What is the location that best describes where you feel your headaches?
Back
Top
Right Side
Left Side
Front
