Section 1 of 1
Gastrointestinal System
Name of individual
Name of individual
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First and last name
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Birth date
Birth date
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Name of person filling the form
Name of person filling the form
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Gastrointestinal System
Gastrointestinal System
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There is a history of Gastrointestinal disease such as irritable bowel, colitis, Crohn’s disease, gastroesophageal reflux, hiatus hernia or ulcer
There is a change in vital signs
There are pain indicators of abdominal shielding or guarding
There are complaints of abdominal discomfort e.g. distension, swelling, firmness, tenderness, pain
There is change in the individual’s level of alertness/awareness
There is nausea and/or vomiting
There is change in bowel pattern e.g. regularity, amount, consistency
There is the date of the last bowel movement known
There have been recent bowel infections, tests, or surgeries
There is a current medication list available … Please provide
There have been recent medication changes
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If Power of Attorney for Care is known, where is the information kept?
If Power of Attorney for Care is known, where is the information kept?
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If Public Guardian and Trustee is known, where is the information kept?
If Public Guardian and Trustee is known, where is the information kept?
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Please provide name and contact information family member if known.
Please provide name and contact information family member if known.
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If the "End of Life Care Directive" for the individual is known, where is it kept?
If the "End of Life Care Directive" for the individual is known, where is it kept?
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DO NOT submit the form. You can simply show the answers to the medical care personnel. To get a hard copy, Right-Click at the form, choose 'Print'. Under the destination drop-down box, you can choose a wireless printer, or 'Save as pdf', or 'Save to Google Drive'.
DO NOT submit the form. You can simply show the answers to the medical care personnel. To get a hard copy, Right-Click at the form, choose 'Print'. Under the destination drop-down box, you can choose a wireless printer, or 'Save as pdf', or 'Save to Google Drive'.
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