Chronic/Functional Digestive Symptoms Evaluation Note

Date/Time: [Encounter date and time]

Clinician: [Clinician name, credentials]

Clinic/Location: [Clinic or location]

Encounter Type: [new / established]

Primary Historian: [patient / caregiver / chart review / combination]; Interpreter: [yes (language) / no / not needed]

(Provenance labeling: Throughout this note, label information as "per patient report," "per outside record (source/date)," or "reviewed in chart" to clarify provenance.)

Chief Concern

[Primary symptom(s) in patient language with duration] (One concise line; include a brief direct quote if it adds clarity.)

History of Present Illness

[Brief narrative summary of symptom trajectory] (Summarize onset, evolution, phenotype, severity, and pattern to support a positive diagnostic approach for functional GI disorders.)

• Timeline and evolution: [Symptom onset (date or best approximation)]; [Inciting events: recent infection, antibiotics, travel, surgery, major stressor]; [Progression: stable / worsening / improving; episodic / continuous]; [Baseline bowel pattern prior to current illness]. (If onset is unclear, provide the best available anchor.)
• Symptom characterization:
  • Abdominal pain: [Location]; [Quality]; [Intensity 0–10]; [Frequency/pattern]; [Relation to defecation: better / worse / unchanged]; [Relation to meals]; [Nocturnal occurrence: yes / no].
  • Bloating and distention: [Perceived bloating vs visible distention]; [Timing/triggers: post-prandial / evening / specific foods]; [Belching pattern]; [Flatulence pattern].
  • Bowel habit: [Stool frequency]; [Bristol Stool Scale types]; [Urgency]; [Tenesmus]; [Incomplete evacuation]; [Incontinence]; [Nocturnal stools: yes / no]. (If constipation: [Straining]; [Sensation of blockage]; [Digital maneuvers].)
  • Upper GI symptoms (if relevant): [Nausea/vomiting]; [Early satiety]; [Post-prandial fullness]; [Heartburn/regurgitation]; [Dysphagia].
  • Systemic symptoms: [Hematochezia/melena]; [Mucus]; [Fever]; [Unintentional weight change]; [Extraintestinal features if IBD or celiac considered: joints, rash, oral ulcers].
• Dietary pattern and triggers: [Typical intake pattern]; [Fiber and hydration]; [Caffeine/alcohol/carbonated beverages]; [Dairy and gluten exposure]; [High-FODMAP patterns]; [Trigger reproducibility]. [Elimination diets tried: what, duration, adherence, response, downsides]. [Nutrition risk flags: restrictive intake, weight loss, fear of eating, limited variety]. (If diet history not obtained, state: "Diet history not assessed today.")
• Medications and substances affecting GI: [Laxatives]; [Antidiarrheals]; [Acid suppressants]; [Antispasmodics]; [Antibiotics]; [Metformin]; [GLP-1 agents]; [NSAIDs]; [Iron]; [Magnesium]; [Opioids]; [Psychotropics]; [Supplements/probiotics/peppermint]; [Cannabis]. (Include dose, frequency, start/stop dates, and patient-reported effects when available.)
• Prior evaluations and treatments: (List chronologically; separate verified records from patient report.)
  • Prior testing: [Test type, date, result, source: patient report / outside record / reviewed in chart].
  • Prior diagnoses communicated to patient: [Diagnosis and by whom].
  • Prior treatments: [Name, dose, duration, adherence (per patient report), response, adverse effects].
  • Diet/behavioral therapy trials: [Type, duration, adherence, response].
• Functional impact: [Work/school impairment]; [Sleep disruption]; [Activity avoidance]; [Patient priorities/goals for this evaluation].

Alarm Features Screen

(Structured checklist; select a status for each item. Do not default to "absent" if not specifically asked.)

• GI bleeding (hematochezia, melena): [present / absent / not assessed] [Details if present]
• Iron-deficiency anemia or anemia concern: [present / absent / not assessed] [Details if present]
• Unintentional weight loss: [present / absent / not assessed] [If present, quantify amount and timeframe]
• Persistent vomiting or progressive dysphagia: [present / absent / not assessed] [Details if present]
• Nocturnal symptoms (pain or diarrhea waking from sleep): [present / absent / not assessed]
• Fever or systemic inflammatory signs: [present / absent / not assessed]
• Family history (first-degree relative): colorectal cancer, IBD, or celiac: [present / absent / not assessed] [Specify condition and relative/age if present]
• New symptom onset at age ≥45: [present / absent / not assessed]
• Immunosuppression, cancer history, or recent high-risk travel: [present / absent / not assessed] [Details if present]

Past Medical History

• GI history: [Prior diagnoses: IBS, GERD, IBD, celiac, peptic ulcer]; [GI surgeries: cholecystectomy, bariatric, other]; [Prior infectious gastroenteritis or C. difficile].
• Relevant non-GI conditions: [Thyroid disease]; [Diabetes]; [Connective tissue disorders]; [Neurologic conditions]; [Pelvic floor disorders]; [Gynecologic history if pelvic symptoms overlap].
• Behavioral health context: [Anxiety]; [Depression]; [Significant stressors]; [Sleep quality]; [Prior psychotherapy or openness to brain-gut behavioral approaches]. (Document observed affect neutrally; do not infer diagnoses without patient report or documentation.)
• Allergies: [Drug/food/environmental allergies and reactions].
• Current medications: [Medication name, dose, frequency]. (Per patient report vs reviewed in chart.)

Family History

• Colorectal cancer or polyps: [Relative and age at diagnosis]
• Inflammatory bowel disease: [Relative and age]
• Celiac disease: [Relative and age]
• Other relevant hereditary conditions: [Details]

Social History

• Diet access and ability to follow diet trials: [Adequacy / barriers]
• Travel or exposure history (if diarrhea): [Details]
• Tobacco use: [Type, amount, duration]
• Alcohol use: [Amount, pattern]
• Occupation constraints (bathroom access): [Details]
• Exercise level: [Details]

Review of Systems

(Include only systems actually reviewed and relevant to the differential. Omit autopopulated negative lists.)

• [GI-related ROS findings]
• [Constitutional, endocrine, rheumatologic, neurologic, dermatologic, or other systems only if specifically reviewed]

Physical Examination

• Vitals: [BP]; [HR]; [Temp]; [BMI]; [Weight today]; [Weight trend if available].
• General: [Appearance]; [Hydration status]; [Nutritional state].
• Abdomen: [Inspection]; [Auscultation if performed]; [Palpation: tenderness location, masses, guarding, rebound].
• Additional findings: [Skin or oral findings if celiac/IBD considered]; [Rectal exam findings if performed]. (If rectal exam deferred: [Rationale].)

Data Reviewed

(Data verified or obtained today; include dates and sources. Separate from patient-reported prior history documented in HPI.)

• Labs: [CBC, CMP, inflammatory markers, celiac serologies, thyroid function, other] (Date, result, source for each.)
• Stool studies: [Calprotectin, pathogens, ova and parasites, other] (Date, result, source.)
• Imaging: [Modality, date, key findings, source].
• Endoscopy: [Dates, key findings, pathology results; note if outside report vs patient report only].
• Prior notes reviewed: [Specialist consultations or hospital records; dates; key takeaways].

Assessment

Summary: [Age, sex] with [dominant symptom cluster] for [duration]. Alarm features [present (specify) / absent as assessed]. Prior workup [summary]. Working impression: [diagnostic impression].

• [Problem 1]: [Most likely diagnosis] — [Supporting rationale].
  • Key differentials: [Prioritized differentials relevant to phenotype].
  • Alarm features and implications: [Impact on testing/urgency].
  • Prior workup adequacy: [Sufficient / gaps identified].
• [Problem 2]: [Diagnosis or symptom complex]. (Include additional problems only if discussed.)

(For functional GI disorder impressions, document the symptom pattern supporting the diagnosis, alarm feature status, and the planned limited targeted exclusion strategy.)

Differential framework: [Inflammatory (IBD, microscopic colitis); Malabsorptive (celiac, carbohydrate intolerance); Infectious; Medication-related; Motility/functional/DGBI; Bile acid diarrhea; SIBO if risk factors; Structural/neoplastic based on age and alarm features; Extra-GI mimics]. (Include categories relevant to this patient's presentation.)

Plan

• Safety and return precautions: [Urgent actions if alarm features present]; [Return-to-care triggers: GI bleeding, dehydration, severe vomiting]; [If escalation deferred, document rationale].
• Diagnostic testing (staged approach):
  • Stage 0 (verification): [Consolidate prior workup; obtain outside records to avoid duplication].
  • Stage 1 (targeted initial testing): [Tests aligned to phenotype and risk; state purpose and how results will change management].
  • Stage 2 (advanced testing): [Reserved for alarm features, abnormal initial results, or refractory course; specify triggers for escalation].
  • Testing deferral (if applicable): [Rationale: adequate prior workup, no alarm features, plan to trial intervention and reassess].
• Diet interventions: [Approach: fiber optimization, low-FODMAP trial, lactose restriction, other]; [Duration]; [Reintroduction plan]; [Referral to GI dietitian if restrictive diet or nutrition risk flags]; [Note if avoiding overly restrictive diet due to risk].
• Brain-gut and behavioral interventions: [Education provided using validating language about gut-brain interaction]; [Referral options considered or placed: gut-directed psychotherapy, CBT, hypnotherapy, diaphragmatic breathing]; [Pelvic floor physical therapy if dyssynergia suspected].
• Pharmacotherapy: (For each medication) [Medication name]; [Indication/symptom targeted]; [Dose]; [Planned duration]; [Key adverse effects reviewed]; [Stop rules if no benefit].
• Tracking plan: [1–3 objective metrics aligned to chief concern: stool frequency and Bristol types, pain severity/frequency, bloating severity, trigger log]; [Tracking frequency]; [How/when data will be reviewed].
• Follow-up: [Timeframe tied to intervention (e.g., 4–8 weeks)]; [Criteria for improvement vs failure]; [Next-step contingencies].
• Orders placed today: [Labs]; [Stool studies]; [Imaging]; [Procedures]; [Referrals: dietitian, pelvic floor PT, behavioral health]; [Patient education provided].

(Missing information handling: If information is unavailable, include a clarifying placeholder such as "date unknown per patient report" rather than leaving ambiguity. Omit entire sections that are not applicable to this encounter.)