Gastrointestinal Assessment Checklist Form
Use this form to record gastrointestinal symptoms, severity, and how they affect daily life. Keep the title exactly as written throughout the form.
Patient Overview
Full Name
*
First Name
Middle Name
Last Name
Age
Sex at Birth
Female
Male
Intersex
Prefer not to say
Other
Today's Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gastrointestinal Symptom Checklist
Which gastrointestinal symptoms are currently present?
*
Abdominal pain
Bloating
Nausea
Vomiting
Diarrhea
Constipation
Heartburn/Reflux
Loss of appetite
Excessive gas
Belching
None of these
Symptom severity
*
Rows
Mild
Moderate
Severe
Abdominal pain
1
2
3
Bloating
4
5
6
Nausea/Vomiting
7
8
9
Diarrhea
10
11
12
Constipation
13
14
15
Heartburn/Reflux
16
17
18
Appetite change
19
20
21
Other common GI symptom
22
23
24
Symptom duration
*
Rows
Less than 1 day
1-3 days
4-7 days
More than 1 week
Abdominal pain
25
26
27
28
Bloating
29
30
31
32
Nausea/Vomiting
33
34
35
36
Diarrhea
37
38
39
40
Constipation
41
42
43
44
Heartburn/Reflux
45
46
47
48
Appetite change
49
50
51
52
Other common GI symptom
53
54
55
56
Please describe any other gastrointestinal symptoms or relevant details
Impact and Follow-up
How much do your symptoms affect eating?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
How much do your symptoms affect daily activities?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
How much do your symptoms affect sleep?
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Additional notes, triggers, or observations
Overall severity or concern rating
1
2
3
4
5
Submit
Should be Empty: