Please complete this brief survey before your visit GI Symptom Survey Today's date* Your name* Date of Birth* Briefly describe your GI problems during the last 3 months* Have you had any nausea? (Feeling like you are going to throw up) Yes No Have you vomited? (Actually thrown up) Yes No Have you had heartburn? (Burning feeling in your chest or throat) Yes No Have you had dysphagia? (Trouble swallowing or food getting stuck in esophagus) Yes No Have you had any abdominal pain? Yes No If yes, please rate on a scale of 1-10 (1 is very mild, 10 is severe) Location of pain? Right Left Upper (above belly button) Lower (below belly button) Have you had any of the following gas symptoms? Belching Yes No Abdominal bloating (stomach is visibly distended at times) Yes No Flatulence (passing gas) Yes No Are you having diarrhea? (Loose or watery bowel movements) Yes No Are you having constipation? (Infrequent bowel movements) Yes No How many bowel movements per day are you having? (If variable, give an average number per day)* Are you having any rectal bleeding? Yes No Have you had any unexplained weight loss? Yes No If yes, please enter the number of pounds lost. Have you taken antibiotics recently? Yes No If yes, when? What antibiotic? Have you traveled outside of the United States in the past year? Yes No If yes, when? Where? Is there any family history of Colon Cancer? Yes No Inflammatory bowel disease (Crohn's or Ulcerative Colitis)? Yes No Celiac disease? Yes No Submit