GASTROENTEROLOGY HEPATOLOGY DIAGNOSTIC & THERAPEUTIC ENDOSCOPY
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1 NORTON GASTROENTEROLOGY CONSULTANTS OF LOUISVILLE 3999 Dutchmans Lane, Medical Plaza 1, Suite 7B, Louisville, KY Phone: (502) Fax: (502) Website: GASTROENTEROLOGY HEPATOLOGY DIAGNOSTIC & THERAPEUTIC ENDOSCOPY Edward Adler, M.D. Martin Mark, M.D. Gerard Siciliano, M.D. Rajesh Joseph, M.D. Bhargab Dixit, M.D. Melissa Quinn, APRN Shelley Wooldridge, APRN Dear Patient: You have an appointment with one of the physicians in our office. Please arrive 30 minutes prior to your scheduled appointment time. We ask you to complete the attached paperwork and either fax ( ) or bring with you to your appointment as an effort to help with the process of your visit. In addition to the paperwork, below is a list of items which are also required. 1. Any recent lab/blood work results from your primary care/referring physician. 2. Any CT, MRI, ultrasound, Hida scans, EGD and colonoscopy reports. 3. Any medical records from your primary care/referring physician. 4. A referral/authorization from your insurance company, if one is required. 5. Insurance cards and picture ID (driver s license). 6. Your co- pay will be due at the time of your visit, as well as any outstanding balance on your account. We look forward to helping you with your patient care needs. Should you have any questions, please contact our office ( ) and we will be glad to assist you. Thank you, Norton Gastroenterology Consultants of Louisville
2 PATIENT INFORMATION FORM PLEASE PRINT Name (first, mi, last): Age: Sex: Male / Female Date of Birth: Social Security No: Marital Status: Address: Home No: Work No: Mobile No: Patient s Employer/Address: Spouse s Name: Emergency Contact /Relationship: Mobile No: Phone No: Primary Care/Referring Physician Name/Number: Pharmacy Name: Pharmacy Phone No: PRIMARY INSURANCE COVERAGE Subscribers Name: Date of Birth: Subscribers Social Security No: Relationship to Patient: Insurance Company: Insurance Address: Policy No: Group No: Subscribers Employer/Address: SECONDARY INSURANCE COVERAGE Subscribers Name: Date of Birth: Subscribers Social Security No: Relationship to Patient: Insurance Company: Insurance Address: Policy No: Group No: Subscribers Employer/Address:
3 PAST MEDICAL HISTORY: (e.g.: high blood pressure, diabetes, heart disease, other): PREVIOUS SURGERIES Type of surgery Date Name of Surgeon Have you had joint replacement? Which joint? When? Surgeon s Name: Have you had heart surgery/valve replacement or heart stenting? When? Cardiologist s Name: Do you have a pacemaker/defibrillator? Other Previous Surgeries and name of surgeons: MEDICATIONS Please circle any of the following medications you are currently taking. Coumadin/Warfarin/Jantoven Pradaxa/Dabigatran Xarelto/Rivaroxaban Plavix/Clopidogrel Effient/Prasugrel Lovenox/Enoxaparin Arixtra/Fondaparinux Brilinta/Ticagrelor Fragmin Eliquis/Apixaban Aggrenox/ASA with Dipyridamole Ticlid/Ticlodipine Persantine/Dipyridamole Physician who manages blood thinner:
4 Name of Other Medications (or attach list) Dose Name of Physician ALLERGIES List allergies to medications and type of reaction: Are you allergic to latex? SOCIAL HISTORY Marital status (please circle): Single Married Divorced Widow/Widower Who lives with you? Education (please circle): High School Some College College Postgraduate What type of work do you perform? Do you smoke? Packs per day: How many years? Did you smoke in the past? Do you drink alcohol? Did you drink in the past? How many drinks per day? Drinks per week: Drinks per month:
5 FAMILY HISTORY Do you have any family members with colon cancer? If yes, who and what age diagnosed: Do you have any family members with colon polyps? If yes, who and what age diagnosed: Do you have any family members with other cancers (uterus, ovary, other)? Other significant family history: GASTROINTESTINAL HISTORY Have you had a sigmoidoscopy? When? When was your last EGD? Have you had a colonoscopy? When? Findings: Do you have history of Barrett s Esophagus? Do you have liver disease? Ulcerative Colitis? Crohn s Disease? Other gastrointestinal diseases? REVIEW OF SYSTEMS (Do you have any of the following symptoms): Allergic/Immunologic Gynecology (if applicable) Allergies (Non Meds) Last Menstrual Period Frequent Infections Post Menopausal HIV/AIDS Uterine Cancer Cervical Cancer Constitution Activity Change Heart Weight Gain Ankle Swelling Unintentional Weight Loss Artificial Valve Fever Chest Pain Fatigue Heart Murmurs Weakness High Blood Pressure History of Heart Attack Mitral Valve Prolapse Ears Pacemaker Hearing Loss Defibrillator Ringing In Ears Palpitations
6 REVIEW OF SYSTEMS continued (Do you have any of the following symptoms): Mouth Gastrointestinal Ulcers Difficulty Swallowing Sores Heartburn Hiatal Hernia Indigestion Nose Nausea Sinus Trouble Vomiting Nose Bleeds Black Tarry Stools Abdominal Pain Belching/Gaseousness Throat Bloating Sore Throat Constipation Diarrhea Frequent Laxative Use Eyes Hemorrhoids Blurred Vision Rectal Bleeding Loss of Sight Hepatitis Liver Disease Gallstones Lungs Inguinal Hernia Asthma Cough Shortness of Breath Urinary Emphysema Difficulty Urinating Wheezing Blood in Urine Sleep Apnea Frequent Urination Tract Infections Kidney Stones Skin Rash Itching Hematologic/Lymphatic Jaundice (yellow eyes or skin) Abnormal Post Surgical Bleeding Anemia Easy Bruising/Bleeding Neurological Dizziness Seizure Disorder Endocrine Epilepsy Diabetes Thyroid Disease Musculoskeletal Arthritis Psychiatric Back Pain Agitation Joint Pain Anxiety Confusion Nervous Infectious Disease Depression Have You Had Tuberculosis Trouble Sleeping Have you Had Histoplasmosis
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