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BARRETT’S ESOPHAGUS QUESTIONNAIRE

Client ________________________________________ Age/DOB _________________

When was Barrett’s esophagus first diagnosed? ___________

History of any of the following on biopsy (check all that apply): □ DYSPLASIA – LOW GRADE (Dates: ___________________________)□ DYSPLASIA – HIGH GRADE (Dates: __________________________)□ MALIGNANCY

Check severity of Barrett’s, if known: □ MILD□ MODERATE□ SEVERE

Check type of treatment (check all that apply): □ MEDICATION□ LASER PROCEDURE/ABLATION (Dates:_______________________)□ SURGERY (Dates: __________________________________________)□ OBSERVATION□ NONE

Has there been a follow-up EGD (endoscopy) since diagnosis & initiation of treatment?

YES□ NO□If yes, dates: ____________________________________________________________

If prior history of any dysplasia, is it resolved on the most recent endoscopy?

YES□ NO□

Current height: __________ Current weight: __________

Any history of unexplained weight loss? YES□ NO□ If yes, how much?_________

Any family history of cancer? YES□ NO□ If yes, details: __________________

List all medications & dosages: _____________________________________________

________________________________________________________________________

Build: _______________

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Have you ever used any nicotine/tobacco products? YES□ NO□ If yes, check all types ever used:

□ Cigarettes (Date last used: ____________) □ Cigars (Date last used: ____________) □ Chewing tobacco (Date last used: ____________) □ Electronic cigarettes (Date last used: ____________) □ Nicotine patch or gum (Date last used: ____________) □ Other (Date last used & type: ____________________________)

List any other medical conditions or impairments: _______________________________ ________________________________________________________________________ ________________________________________________________________________ *Please include copies of any endoscopies and pathology reports if possible.