Medical Diagnostic Form

The questions you're about to answer will provide our licensed medical team the information needed to diagnose and treat your symptoms. Once you finish, you will be presented with a payment and scheduling page for your medical provider consultation.

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Please list your name as it appears on your driver's license.

Chemotherapy, active cancer, HIV, immune disorders, long-term use of prednisone or other medication that suppresses the immune systemActive heart failure, history of strokes, kidney failure, or liver failureOrgan transplantation or absence of a spleenChronic diagnosis of inflammatory bowel disease (IBD), including chronic ulcerative colitis or Crohn's diseaseChronic pancreatitisCeliac diseaseNone of the above

If "None of the above" is selected, please ensure that no other options are selected

NoneLess than 7 drinks7 to 14 drinksMore than 14 drinksLess than 14 drinks on average in one week but ≥ 5 drinks in one sitting

NoneLess than 1 drink1 to 2 drinksMore than 2 drinksLess than 2 drinks on average in one day but sometimes ≥ 5 drinks in one sitting

Note: 1 standard drink is 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of distilled spirits.

1 is Mildest, 10 is Most Severe

Constant (present all the time)Intermittent (comes and goes)

Never (have not had abdominal pain/current episode of pain has not recurred in the past 3 months)Less than 1 day a month in the past 3 months1 – 3 days a month in the past 3 months1 day a week in the past 3 monthsMore than 1 day a week in the past 3 monthsEvery day in the past 3 months

AlwaysSometimesNever

Fever (temperature above 100.4ºF)Recent abdominal injuryRecent abdominal surgery in the last 30 daysNone of the above

If "None of the above" is selected, please ensure that no other options are selected

ConstipationDiarrheaBothNone of the above

NauseaVomitingNone of the above

If "None of the above" is selected, please ensure that no other options are selected

TodayYesterday2-3 days ago4-7 days ago1 week to 1 month agoMore than 1 month ago

If "None of the above" is selected, please ensure that no other options are selected

Chronic diagnosis of inflammatory bowel disease (IBD), including chronic ulcerative colitis or Crohn's diseaseAbdominal cancer (stomach, liver, large intestine/colon, small intestine, pancreas, gallbladder, esophagus, and rectum)Celiac diseaseDiverticulitisNone of the above

If "None of the above" is selected, please ensure that no other options are selected

NoYes, please specify

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Medical Diagnostic Form

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