Patient Name

First Name

Last Name

Patient Date of Birth

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DD

YYYY

Patient Phone

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Gastroenterology

Abnormal Bowel Movements

Constipation

Diarrhea

Excessive Gas

Pale or Light-Coloured Stool

Abdominal Pain or Bloating

Dysphagia

Unexplained Weight Loss

Rectal Bleeding

Frequent Heartburn

Jaundice

Peptic Ulcers

Difficulty Swallowing

Age 45+ for Regular Colorectal Cancer Screening

Other

Gastroenterology Consultation

Other