Advanced Gastroenterology Associates L.L.C Homayoon Mahjoob

Advanced Gastroenterology Associates L.L.C
Homayoon Mahjoob, MD, M.S.P.H
[email protected]
Contact: (301) 352- 7771 Fax: (800) 681-5070
Website: www.AdvancedGiWorld.com
REGISTRATION FORM
Primary Care Physician:
Today’s date:
PATIENT INFORMATION
Patient’s Last Name:
First:
Middle:
Marital Status (circle one)
Single / Mar / Div / Sep
Is this your legal name? If not, what is your legal name?
 Yes
 No
Street Address:
Birth date:
/
City:
Social Security #:
Occupation:
(Former name):
Home #:
Employer:
Sex:
M
Zip code:
/
State:
Cell#
F
Email Address:
Employer Address:
 Physician, Name:_________________
Referred by:
Age:
Employer Phone Number:
 Hospital
Phone:_________________  Insurance Plan
 Family
 Internet/Directory
 Friend
 Other:
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for bill:
Birth date:
Address (if different):
/
/

 No
Yes
Is this person a patient
here?
Occupation:
Employer:
Home phone no.:
(
)
Employer address:
Employer phone no.:
(
Is this patient covered by insurance?
Subscriber’s name:
Please indicate primary insurance:
 Yes  No
Subscriber’s SSN
Birth date:
/
Patient’s relationship to
subscriber:
Name of secondary insurance (if
applicable):
Patient’s relationship to
subscriber:
 Self
 Spouse
Group no.:
 Spouse
Policy no.:
/
 Child
 Child
Copayment:
$
 Other
Subscriber’s name:
 Self
)
Group no.:
Policy no.:
 Other
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same
Relationship to
address):
patient:
Home phone#:
Work phone#:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I
understand that I am financially responsible for any balance. I also authorize Advanced GI Associates LLC or insurance company to
release any information required to process my claims. Please note you will receive only one statement for any patient balance
due. If not paid within 30 days, the account will be considered for collections and associated fees unless arrangements
have been made with our office.
Patient/Guardian signature
Date
MEDICAL HISTORY
Name:_______________________
Date: ________ Age:___________
Referring Physician: ________________________________
Main Concern for Visit: ________________________________
DOB: __________
PAST MEDICAL HISTORY
HAVE YOU BEEN DIAGNOSED
YES NO IF YES, PLEASE EXPLAIN DISEASE AND TIME OF DIAGNOSIS
WITH ANY OF THE FOLLOWING?
Diabetes
High Blood Pressure
Abnormal Cholesterol
Stroke
Heart Disease
Lung Disease
Kidney Diseases
Gastrointestinal Diseases
Liver Diseases
Pancreas Diseases
Gallbladder Diseases
Colon Polyps
Musculoskeletal Diseases
Joint Diseases
Vascular Diseases
Cancerous Diseases
HAVE YOU BEEN EXPERIENCING ANY
YES NO IF YES, PLEASE EXPLAIN HOW OFTEN AND WHEN SYMPTOMS OCCUR
OF THESE SYMPTOMS?
Eyes: Jaundice/Double vision
Ear, Nose & Throat: Sore throat/ Nasal
congestion/Ear pain
Respiratory: shortness of breath/
Cough/sputum(phlegm)/Wheezing/
Blood in sputum (Hemoptysis)
Cardiovascular: Chest pain/
Palpitation/Irregular heart beat/
Calf pain/ Claudication ( Pain when
walking)/Leg swelling (edema)
Skin: Rash/Abrasions/Discoloration
Neurologic: Tingling/Abnormal balance
Psychiatric: Anxiety/ Depression/
Mania/ Suicidal/
Delusional/Hallucinational
Gastrointestinal and Constitutional
Weight loss
Weight gain
Eating Disorders
Difficulties Swallowing
Painful swallowing
Regurgitation
Heartburn
Nausea
Vomiting
Vomiting Blood
Abdominal Distention (swelling)
Patient Name:
HAVE YOU BEEN EXPERIENCING ANY
OF THESE SYMPTOMS?
Bloating
Diarrhea
Constipation
Blood in stool
Change of color in stool
Stool Inconsistency
Itching
Regular Bowel Movement
Hemorrhoids
Other GI symptoms not listed
FAMILY HISTORY
Do you have family history of any of
the following?
History of Colon Cancer
History of Colon Polyp
Date:
YES NO
YES
Referring Physician:
IF YES, PLEASE EXPLAIN HOW OFTEN AND WHEN SYMPTOMS OCCUR
NO
Relative
History of Other GI malignancies
(Pancreas, Liver, Gallbladder, Stomach,
Esophagus, Intestine)
Other past family history
PLEASE LIST ALL PAST SURGICAL HISTORY/HOSPITALIZATIONS
Date:
1.
2.
3.
4.
5.
PAST PROCEDURE HISTORY
Colonoscopy
Upper Endoscopy
ERCP
YES/NO
YES/NO
YES/NO
Year done:
Year done:
Year done:
Please provide your Pharmacy Name and Address:
______________________________
______________________________
______________________________
Pharmacy Phone#: (____)__________ Fax: (____)__________
Findings:
Findings:
Findings:
Patient Name: ___________________________ DOB: ____________
ALLERGIES (Yes/No)
Referring Physician: ____________________
If Yes:
List All Allergies including:
Medication, Food, and Environmental
Brief description of allergic reaction:
1.
2.
3.
4.
5.
List All CURRENT Medications and Dosages:
Please make sure to include the following if any:
NSAID’s use: (Aspirin, Naproxen, Motrin, Ibuprofen, Aleve)
Anticoagulation/Blood Thinners: ( Plavix, Heparin, Warfarin)
Laxatives, Herbal Medicine, Pain Medications
Medication name:
Dose:
Reason:
1 1.
2.
3.
4.
5.
6.
7.
List All DISCONTINUED Medications and Dosages:
Medication name:
Dose:
Reason:
1.
2.
3.
4.
SOCIAL HISTORY
Do you drink alcohol?
Are you a smoker?
Do you use illicit Drugs?
YES/NO
YES/NO
YES/NO
If Yes, How Often?
If Yes, How Often?
If Yes, How Often?
Advanced GI Associates, LLC
Dr. Homayoon Mahjoob, M.D., M.S.P.H.
12150 Annapolis Road Suite 312 Glendale, MD 20707
Office: (301) 352 7771
Fax: (800) 681 5070
Consent for Release and Use of Confidential Information
I,
hereby
(Name of Patient or Authorized Agent)
give my consent to Advanced GI Associates, LLC., to use or disclose, for the purpose of carrying out treatment,
payment, or health care operations, all information contained in the patient record of
.
I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at
any time by giving written notice of my desire to do so, to the physician. I also understand that I will not be
able to revoke this consent in cases where the physician has already relined on it to use or disclose my health
information. Written revocation of consent must be sent to the physician’s office.
I understand that I have the right to request that the practice restricts how my individually identifiable health
information is used and/or disclosed to carry out treatment, payment or health operations. I understand that
the practice does not have to agree to such restrictions, but that once such restrictions are agreed to, the
practice and their agents must adhere to such restrictions.
Name:
Signed:
If not the patient, please specify your relationship to the patient
Date: