Visit Preparation for GI Symptoms

To Complete the Table below click on and review the Symptoms List and type the symptoms you are experiencing into the fields; next type in your medications and dosages. Finally, copy/scan the completed Table and paste it into an email* and send it to your doctor prior to your office visit. You can send it by regular email or by the email facility in your Patient Portal (access to the patient portal is set up with a link provided by your doctor's office)

First name: Last name:

Birthdate: Gender:
Home Phone: Cell:


List of Symptoms, Medications and Dosages

GI Symptoms List Medications/Strength Times per day