Coastal Digestive Diseases, P.C. MA New Pt Ht

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1 Coastal Digestive Diseases, P.C. MA New Pt Ht Interview Form Limited Use Only Estab Pt Wt Name Nickname DOB Address Occupation Social Security # Married Single Address: Divorced Widowed Check Contact Preference: Cell Phone # ***Please provide ALL #'s*** Home Phone# Work Phone # Primary Care Doctor (PCP) Employer Patient Portal Letter No Preference Pharmacy Location Do you have any allergies? Current Medication(s): Name Strength # Times/Day Name Strength # Times/Day What is the reason for your visit today? Review of Systems Cardiovascular Yes No Hematologic/Lymphatic Yes No Neurological Yes No None None None Chest Pain Easy Bruising Dizziness Dyspnea with Exercise Prolonged Bleeding Fainting Irregular Heart Beat Frequent Headaches Palpitations Skin Migraines Syncope None Numbness/Tingling Allergies Seizures Constitutional Yes No Dryness Tremors None Hives Vertigo Fatigue Itching Memory Loss Fever Loss of Appetite Lesions Psychiatric Yes No Weight Gain Rashes None Weight Loss Anxiety Musculoskeletal Yes No Depression Gastrointestinal Yes No None Difficulty Sleeping None Arthritis Hallucinations Abdominal Pain Back Pain Nervousness Abdom Swelling/Distention Gout Panic Attacks Change in Bowel Habits Joint Deformity Paranoia Constipation Joint Pain Diarrhea Muscle Weakness Respiratory Yes No Gas Stiffness None Heartburn Asthma Cough Nausea Dyspnea Rectal Bleeding Excessive Sputum Stomach Cramps Coughing up Blood Vomitting Shortness of Breath with Exercise Difficulty Swallowing Wheezing Have you had any of the following: Y N Description Surgery? Non Surgical Hospitalization? New Medical Problems? Worsening of Prior Medical Problems? Blood Tests? X-Rays? ER Visits? Can you climb a flight of stairs or walk 2 city blocks without difficulty? Patient Signature Date Rev. 010/13

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3 Coastal Digestive Diseases, P.C. MA New Pt Ht Interview Form Limited Use Only Estab Pt Wt Name Nickname DOB Address Occupation Social Security # Married Single Address: Divorced Widowed Employer Preferred Phone Number Home Work Cell May we contact you at work? Contact home voice mail? May we leave a message? Who is your Primary Care Doctor (PCP)? What is the name of your Pharmacy? Location Do you have any allergies? Current Medication(s): Name Strength # Times/Day Name Strength # Times/Day What is the reason for your visit today? Review of Systems Cardiovascular Yes No Hematologic/Lymphatic Yes No Neurological Yes No None None None Chest Pain Easy Bruising Dizziness Dyspnea with Exercise Prolonged Bleeding Fainting Irregular Heart Beat Frequent Headaches Palpitations Integumentary Migraines Syncope None Numbness/Tingling Allergies Seizures Constitutional Yes No Dryness Tremors None Hives Vertigo Fatigue Itching Memory Loss Fever Loss of Appetite Lesions Psychiatric Yes No Weight Gain Rashes None Weight Loss Anxiety Musculoskeletal Yes No Depression Gastrointestinal Yes No None Difficulty Sleeping None Arthritis Hallucinations Abdominal Pain Back Pain Nervousness Abdom Swelling/Distention Gout Panic Attacks Change in Bowel Habits Joint Deformity Paranoia Constipation Joint Pain Diarrhea Muscle Weakness Respiratory Yes No Gas Stiffness None Heartburn Asthma Cough Nausea Dyspnea Rectal Bleeding Excessive Sputum Stomach Cramps Coughing up Blood Vomitting Shortness of Breath with Exercise Difficulty Swallowing Wheezing Have you had any of the following: Y N Description Surgery? Non Surgical Hospitalization? New Medical Problems? Worsening of Prior Medical Problems? Blood Tests? X-Rays? ER Visits? Can you climb a flight of stairs or walk 2 city blocks without difficulty?

4 Patient Signature Date Rev. 05/13

5 New Coastal Digestive Diseases, P.C. Ht Established Interview Form Limited Wt Name DOB Nickname Occupation: Social Security # Married Single Address: Divorced Widowed Employer Preferred Phone Number Home Work Cell May we contact you at work? Contact home voice mail? May we leave a message? Who is your Primary Care Doctor (PCP)? What is the name of your Pharmacy? Location Do you have any allergies? Current Medication(s): Name Strength # Times/Day Name Strength # Times/Day What is the reason for your visit today? Review of Systems Cardiovascular Yes No Hematologic/Lymphatic Neurological Yes No None None None Chest Pain Easy Bruising Dizziness Dyspnea with Exercise Prolonged Bleeding Fainting Irregular Heart Beat Frequent Headaches Palpitations Integumentary Migraines Syncope None Numbness/Tingling Allergies Seizures Constitutional Yes No Dryness Tremors None Hives Vertigo Fatigue Itching Memory Loss Fever Loss of Appetite Lesions Psychiatric Yes No Weight Gain Rashes None Weight Loss Anxiety Musculoskeletal Yes No Depression Gastrointestinal Yes No None Difficulty Sleeping None Arthritis Hallucinations Abdominal Pain Back Pain Nervousness Abdom Swelling/Distention Gout Panic Attacks Change in Bowel Habits Joint Deformity Paranoia Constipation Joint Pain Diarrhea Muscle Weakness Respiratory Yes No Gas Stiffness None Heartburn Asthma Cough Nausea Dyspnea Rectal Bleeding Excessive Sputum Stomach Cramps Coughing up Blood Vomitting Shortness of Breath with Exercise Difficulty Swallowing Wheezing Have you had any of the following: Y N Description Surgery? Non Surgical Hospitalization? New Medical Problems? Worsening of Prior Medical Problems? Blood Tests? X-Rays? ER Visits? Can you climb a flight of stairs or walk 2 city blocks without difficulty?

6 Patient Signature Date

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