New Patient Forms - Southwest Gastroenterology Associates

80LANDI
NGSDRI
VESUI
TE205
WASHI
NGTON,PA15301
Current Height ______ft______inches Current Weight ____________lbs
Medications (List all current prescription and non prescription medication. Attach additional pages if necessary)
Medication Name
Dosage
Frequency/Day
Medication Name
Dosage
Frequency/ Day
Are you currently taking blood thinners (Coumadin/ Warfrain, Plavix, Aggrenox, Ticlid)?
Yes
Are you currently taking aspirin/ NSAIDs (Ibuprofen, Advil, Naproxen, Aleve, etc)?
Yes
No
No
Your Pharmacy Name/ Address____________________________________________________________
Telephone #___________________________________________________________________________
Social History
Occupation____________________________________________________________________________
Tobacco:
Never smoked
Current Smoker: How many packs/day______for how many years______
Former Smoker: How many packs/day ______for how many years___ Year quit______
Alcohol:
None
Beer
Wine
Liquor
How often (i.e. # drinks per day or week, please describe usage: ________________________
Caffeine: # cups per day: ___________________________
Recreational Drugs:
Yes
No. If yes, please usage:_____________________________________
_____________________________________________________________________________________
Family History (Please include which family member and age of diagnosis if known)
Colon Cancer
Colon Polyps
Ulcerative Colitis
Crohn's Disease
Celiac Disease
Other GI Cancer
Liver Disease
Breast Cancer
Ovarian Cancer
Other Cancer
Diabetes Mellitus
Heart Disease
Other
Mother
Father
Siblings
Grandparents
Others
Systems Review (Do you have or have you recently experienced any of the following?)
DIGESTIVE SYSTEM
Difficulty in Swallowing
Solids
Liquids
Heartburn/ Esophageal Reflux
Regurgitation
Nausea
Vomiting
Indigestion
Early Satiety
Abdominal Pain
Right Upper Quadrant
Right Lower Quadrant
Left Upper Quadrant
Left Lower Quadrant
Bloating/ Belching / Gaseousness
Gastrointestinal Bleeding
Change of Bowel Habits
Constipation
How many bowel movements per week? ____
Hard/lumpy Stool
Difficult passage of stools (i.e. straining
Excessively to defecate)
Sensation of incomplete evacuation
Diarrhea
How many bowel movements daily? ______
Loose stool
Blood in Stool
Black Stool
Rectal Bleeding ( in stool,commode,toliet paper)
Unintentional Weight Loss
Hemorrhoids
Anal/Rectal Pain
Fecal incontinence/soiling
Jaundice
EARS,EYES,NOSE, MOUTH THROAT
Hearing Loss
Ear Pain/ Ringing
Eye Pain
Blurry Vision
Eye Redness
Mouth Ulcers/Sores
Sore throat
Hoarseness
SKIN
GENERAL
Weight loss ( how much: ___-lbs)
Fever/ Chills
Fatigue/ Weakness
Loss of Appetite
RESPIRATORY
Shortness of breath
Wheezing
Cough
CARDIAC
Chest Pain
Palpitation
Irregular heartbeat
Swelling in legs
GENITOURINARY
Are you pregnant?
Blood in Urine
Difficulty with urination
Frequency or painful urination
MUSCULOSKELETAL
Joint pain/ swelling
Back Pain
Problems Walking
Muscle weakness
Muscle pain
NEUROLOGIC
Numbness/ tingling
Weakness
Dizziness
Headache
Seizure
Tremor
HEMATOLOGIC
Easy bruising/ bleeding
ENDOCRINE
Heat/ cold intolerance
Excessive thirst
PSYCHIATRIC
Rash
Depression
Anxiety
Excessive stress
DEMOGRAPHICS
DATE OF BIRTH:
AGE:
SOCIAL SECURITY NUMBER:
ADDRESS:
HOME TELEPHONE #:
Do we have permission to leave a message on a voice recorder?
ALTERNATE TELEPHONE #:
YES
NO
OCCUPATION:_________________________________________________________________________
EMPLOYER:
MARITAL STATUS
SINGLE
MARRIED
WIDOWED
NAME OF SPOUSE:
LIVING ARRANGEMENTS
ALONE
SPOUSE/ SIGNIFICANT OTHER
SUPERVISED LIVING
IN CASE OF EMERGENCY CONTACT
NAME:_______________________________________________________________________________
RELATIONSHIP:________________________________________________________________________
PHONE:
INSURANCE INFORMATION
SUBSCRIBER NAME:
RELATIONSHIP TO PATIENT:
DATE OF BIRTH:
INSURANCE COMPANY:
IS THIS PATIENT COVERED BY ANY SECONDARY INSURANCE?
YES
NO
SECONDARY INSURANCE IF APPLICABLE
SUBSCRIBER NAME:
RELATIONSHIP TO PATIENT:
DATE OF BIRTH:
INSURANCE COMPANY:
ASSIGNMENT AND RELEASE
I UNDERSIGN CERTIFY THAT I OR MY DEPENDENT HAVE INSURANCE WITH_______________________________________
AND ASSIGN DIRECTLY TO SOUTHWEST GASTROENTEROLOGY ASSOCIATES ALL INSURANCE BENEFITS, IF ANY, OTHERWISE
PAYABLE TO ME FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER
OR NOT PAID BY INSURANCE. I HEREBY AUTHORIZE THE DOCTOR TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE
PAYMENT OF BENEFITS. I AUTHORIZE THE USE OF THIS SIGNATURE ON ALL INSURANCE SUBMISSIONS.
MEDICAL AUTHORIZATION
I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE BENEFITS APPLICABLE, MEDIGAP BENEFITS BE MADE EITHER TO ME OR
ON MY BEHALF TO SOUTHWEST GASTROENTEROLOGY ASSOCIATES FOR ANY SERVICES FURNISHED TO ME BY THE PROVIDER.
TO THE EXTENT PERMITTED BY LAW I AUTHORIZE ANY HOLDER OF MEDICARE OR OTHER INFORMATION ABOUT ME TO
RELEASE TO THE CENTER FOR MEDICARE AND MEDICAID SERVICES, MEDIGAP INSURER, AND THEIR AGENTS AND
INFORMATION NEEDED TO DETERMINE THESE BENEFITS FOR RELATED SERVICES.
_________________________
RESPONSIBLE PARTY SIGNATURE
_______________________
RELATIONSHIP
_________________
DATE
HIPPA
I GIVE MY PERMISSION FOR SOUTHWEST GASTROENTEROLOGY ASSOCIATES TO DISCUSS ANY INFORMATION PERTAINING TO
MY MEDICAL CARE OR CONDITION WITH THE FOLLOWING PEOPLE (FAMILY MEMBER, FRIEND ETC) LISTED BELOW
1.__________________________________________ 2.____________________________________________