Patient Interview Form
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- Calvin Barnaby Underwood
- 6 years ago
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1 Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Please check one as your preferred for communications Personal: Work: Race Select one or more White Unknown Black or African American Asian Prohibited by state law American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino Not Hispanic or Latino Prohibited by state law Sex Male Female Other Preferred Language English Spanish; Castilian Contact Preference Letter Portal Message Reminder Preference I would like to receive preventive care and follow up care reminders. Yes No Allergies Patient has no known allergies Patient has no known drug allergies Aspirin Demerol Iodine Morphine Penicillins Sulfa Valium Versed Other
2 Page 2 of 5 Current Medications Name Dose How taken? Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Yes No Pharmacy Name Address Phone Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Alcohol Type Quantity Number Frequency I quit using alcohol Exercise Type Quantity Number Frequency Tobacco Smoking Status Current every day smoker Smoker, current status unknown Current some day smoker Light tobacco smoker Former smoker Heavy tobacco smoker Never smoker Unknown if ever smoked
3 Page 3 of 5 Current Symptoms Allergic/Immunologic flu HIV exposure persistent infections pneumonia Strong Allergic Reaction Cardiovascular ankle swelling chest pain murmur palpitations shortness of breath (lying down) shortness of breath (with exercise) Constitutional fatigue fever loss of appetite weight gain weight loss malaise night sweats Genitourinary blood in urine urinary frequency frequent urinary infections kidney disease/failure kidney stones sexual difficulty heavy periods sexually transmitted diseases Painful urination Hematologic/Lymphatic easy bruising prolonged bleeding swollen glands Integumentary dryness hives itching lesions rashes jaundice Psychiatric anxiety/panic depression difficulty sleeping inability to concentrate loss of interest in enjoyable activites suicidal thoughts Respiratory COPD asthma excessive sputum Endocrine cold intolerance excessive thirst hair/nail changes ENMT hearing loss nose bleeds sore throat difficulty swallowing hoarseness Eyes night sensitivity pain visual decline Musculoskeletal back pain joint pain muscle pain arthritis joint deformity muscle weakness Neurological dizziness frequent headaches numbness or tingling fainting migraine seizures tremors Gastrointestinal abdominal pain belching black stools bloating change in bowel habits constipation dairy intolerance diarrhea difficulty swallowing flatulence heartburn/indgestion hemorrhoids nausea pain with bowel movement rectal bleeding rectal urgency/incontinence vomiting gas jaundice stomach cramps
4 Page 4 of 5 Immunizations Influenza, seasonal, injectable Pneumonia Hepatitis A Hepatitis B TB/PPD Past or Present Medical Conditions Anemia Arthritis Rheumatoid Arthritis Back Pain (chronic) Cancer (type) Diabetes Mellitus Atrial Fibrilation Asthma Cirrhosis Colon cancer Colon polyps Diverticulitis Diverticulosis Peptic Ulcer Disease Fatty Liver Gallstones Glaucoma Gout Heart Attack Hepatitis (type) High Blood Pressure HIV/AIDS Irregular Heart Beat Kidney Disease Osteoporosis Pancreatitis Paralysis Parkinsons Pneumonia Reflux Rheumatic Fever Skin Cancer Stroke TB (Tuberculosis) Vascular Disease Other Seizures TB Skin Test Positive IBS STD (STI) Thyroid disorder Diagnostic Studies/Tests Endoscopy Colonoscopy Sigmoidoscopy Pacemaker Previous Procedures Appendectomy Breast C-Section Cardiac Surgery Colon Resection ERCP Hysterectomy Gallbladder Removed Joint Replacement Hernia Repair Hemorrhoidectomy Hiatal Hernia Surgery Kidney Liver Biopsy Obesity Surgery Ovary Surgery Prostate Stomach Thyroid Tonsillectomy Tubal Ligation Other
5 Page 5 of 5 Family Medical History No knowledge of family history No family history of Colon cancer Colon Polyps Health Status Healthy Deceased/At Age Diagnoses Alcoholism Cancer Other: Colon Cancer Colon Polyps Diabetes Heart Trouble High Blood Pressure Liver Disease Lung Disease Pancreatic Cancer Stomach Cancer Other: Reviewed with Patient Parent Guardian Not Present Signature Signature Date
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: MRN: Last Name: Date Of Birth: Contact Preference Email Telephone call- Work Telephone call - Home Email Please check one as your preferred
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Patient Interview Form Patient Information First Name: Last Name: Date of Birth: Age: Email Personal: Race Select one or more Referring Physician White Black or African Asian American Indian Native Hawaiian
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Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select
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Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
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Page 1 of 7 Patient Interview Form UNIVERSITY GASTROENTEROLOGY 33 Staniford Street, Providence, RI 02905 Phone 401-421-8800 Fax 401-421-2492 Patient Information First Name: MRN: Age: Last Name: Date Of
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Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: tes: Contact Preference Email Telephone call/leave message Patient declines to specify Email Please check one
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Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information
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Page 1 of 5 Gastroenterologists: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Samuel J. Tarwater, MD Travis J. Rutland, MD Gastroenterologists: Marc L.
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Page 1 of 5 Physicians: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Physicians: Samuel J. Tarwater, MD Travis J. Rutland, MD Ashwani Kapoor, MD Pathologist:
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Page 1 of 5 Telephone: 703-698-8960 Fax: 703-828-0961 www.novagi.com Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Race Select one or more White Unknown Black or African
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Page 1 of 6 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more White
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Page 1 of 6 STEPHEN G. ABSHIRE, M.D. JAMES N. ARTERBURN, M.D. ERIC P. TRAWICK, M.D. JACOB R. KARR, M.D. SYLVIA OATS, ANP-BC SUSAN MIEDECKE, FNP-BC CINDY LANDRY, ANP-BC 1211 Coolidge Blvd. Suite 303 Lafayette,
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Page 1 of 6 Patient Interview Form MONMOUTH GASTROENTEROLOGY, LLC A Division of Allied Digestive Health, LLC 1912 Route 35 South, Second Floor Oakhurst, NJ 07755 (732) 389 5004; FAX (732) 548 7408 Nadeem
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Page 1 of 7 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
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