Constipation Chief Complaint Intake Form

Full Name

First NameLast Name

Date of Birth

Date

Contact Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How long have you been experiencing constipation?

How often do you have bowel movements?

Please describe the consistency of your stool (select all that apply):

Do you experience any of the following symptoms? (Select all that apply)

Please list any current medications or supplements you are taking:

Do you have any of the following medical conditions? (Select all that apply)

Please describe your typical daily diet (briefly):

How much water do you drink per day?

Have you tried any treatments for constipation? If yes, please specify:

Is there a family history of gastrointestinal problems?

Please provide any additional information about your symptoms or concerns: