GASTROCARE, P.C. Contact Preference: HOME: Cell #: Office #: REASON FOR VISIT: Allergies: Current Medications (Name/Dose/How taken):
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1 GASTROCARE, P.C. DR. A.B. REDDY, M.D., F.A.C.G. DR. REKHA KHURANA, M.D. Referring Physician: First Name: Date of Birth: Last name: Age: Pharmacy (include location): Fax Number: Address: Gender: Male Female Race: American Indian / Alaskan Native / Asian / African American / Caucasian / More than one race / Pacific Islander / Refused Ethnicity: Hispanic / Latino / Non-Hispanic / Declined Language: English / Spanish / Other Contact Preference: HOME: Cell #: Office #: REASON FOR VISIT: Allergies: Current Medications (Name/Dose/How taken): Diagnostic Studies/Tests: Past or Present Medical Conditions: Cancer: Type: Peptic Ulcer: Heart Attack: Diabetes: High Blood Pressure: Hepatitis: Type: Stroke: Emphysema: Seizures: Colon Polyps: Ulcerative Colitis/Crohns: HIV: Thyroid Problems: Gastrointestinal Symptoms: None: Black Stool: Difficulty Swallowing: Loss of appetite: Abdominal Pain: Abdominal Swelling: Change in bowel habits: Constipation: Diarrhea: Gas: Heartburn/reflux: Jaundice: Nausea: Rectal bleeding/blood in stool: Stomach Cramps: Vomiting: Blood in vomit: Weight Loss:
2 Review of Systems: Allergic/Immunologic: HIV exposure Cardiovascular: Chest Pain Dyspnea with exercise Irregular heart beat Palpitations Endocrine: Excessive thirst Diabetes Genitourinary: Frequent urination Difficulty urinating Blood in urine Musculoskeletal: Arthritis Lupus Fibromyalgia Neurological: Frequent headaches Seizures Constitutional: Fatigue Fever Loss of appetite Weight loss ENMT: Ear pain Nose bleeds Photophobia Sore throat Integumentary: Allergies Dryness Hives Jaundice Rashes Respiratory: Asthma Cough Dyspnea Psychiatric: Anxiety Depression Difficulty sleeping Nervousness Stress factors Previous Procedures/Surgeries: Social History: Occupation: Marital Status: Single / Married / Divorced / Widowed Alcohol: None Duration: Type: Quantity: Frequency: Caffeine: None Duration: Type: Quantity: Frequency: Tobacco: Current Every Day Smoker Quantity: / Former Smoker / Never Smoked / Chew Tobacco How long: Recreational Drug Use: Never / In Past / Current Use If yes, type: Family Medical History: Family history noncontributory Colon Cancer Ulcerative Colitis/Crohn s Family history of Colon polyps Liver Disease/Cirrhosis Esophageal Cancer Stomach Cancer Other Cancers, type Type: Relationship: _
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6 GASTROCARE, P.C. AND TUSCALOOSA ENDOSCOPY CENTER A.B. REDDY, M.D., F.A.C.G. REKHA KHURANA, M.D. AUTHORIZATION FOR TREATMENT The undersigned has been informed of the treatment considered necessary for the patient whose name appears on the bottorn and that the treatment and procedures will be performed by the above physicians, and whomever he may designate as assistants. Authorization is hereby granted for such treatment and procedures. The undersigned has read the above authorization and understands the same and certifies that no guarantee or assurance is made as to the results that may be obtained. Printed Name of Patient Date Signature of Patient or Authorized Person Witness Relationship to Patient ************************************************************************************ AUTHORIZATION FOR RELEASE OF INFORMATION Authorization is hereby granted to release to the Primary or Consulting / Referring Physician such information as may be necessary for the completion of my hospitalization claims. Signature of Patient or Authorized Person Relationship to Patient ************************************************************************************ AUTHORIZATION TO PAY THE PHYSICIAN / FACILITY I hereby authorize payment for services provided in the office, endoscopy center and the hospital directly to the above physician, otherwise payable to me. I understand I am financially responsible for the medical and/or physician charges not covered by this authorization. Signature of Patient or Authorized Person Relationship to Patient All authorizations must be signed by the patient or by an authorized person in the case of a minor or when a patient is physically or mentally incompetent.
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