ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG
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1 ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG DATE SOC. SEC. NUMBER FULL NAME DATE OF BIRTH ADDRESS: STREET TOWN STATE ZIP PHONE: HOME WORK CELL EMPLOYER OCCUPATION ADDRESS EMERGENCY CONTACT: NAME RELATIONSHIP PHONE PRIMARY INSURANCE INFORMATION: PROVIDER NAME DEDUCTIBLE AMOUNT INSURED NAME INSURED SS# DOB INSURANCE ID# GROUP# RELATIONSHIP TO PATIENT COPAY AMOUNT SECONDARY INSURANCE INFORMATION: PROVIDER NAME INSURED NAME INSURED SS# DOB INSURANCE ID# GROUP# RELATIONSHIP TO PATIENT COPAY AMOUNT REFERRING PHYSICIAN PRIMARY CARE PHYSICIAN ADDRESS PHONE# I understand that I am personally responsible for all fees incurred for the medical services rendered, regardless of my possessing any medical insurance coverage or any existing agreement between the Physician and such insurance company regarding fees, methods of payment or handling of claims. I request that the payment of benefits be made on my behalf to Dr. Ali S. Karakurum for services rendered by him. I authorize any holder of medical information about me to release to my insurance carrier any information needed to determine these benefit or benefits payable for related services. PATIENT/GUARANTOR SIGNATURE DATE
2 ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. Patient Health Information Form NAME: TODAY S DATE: DOB REASON FOR TODAY S VISIT: MEDICATION ALLERGIES: PAST MEDICAL HISTORY: o Anemia o Asthma o Atrial fibrillation o Breast Cancer o Chronic Lung Disease o Cirrhosis o Colitis o Colon Cancer o Colon polyps o Crohn s Disease o Depression o Diabetes o Diverticulitis o Diverticulosis o Fatty Liver o Gallstones o Glaucoma o Hemorrhoids o Heart attack o Hepatitis B o Hepatitis C o Hiatal hernia o High blood o History of o HIV o Irritable Bowel Pressure suicide attempt syndrome o Lactose intolerance o Liver Disease o Osteoporosis o Pancreatitis o Stroke o Tuberculosis o Ulcer o Ulcerative colitis o NONE o Other PAST SURGICAL HISTORY: o Appendectomy o Breast o C-Section o Cardiac Surgery o Cardiac Defibrillator/Pacemaker o Cardiac Stent o Colon Resection o Colonoscopy o EGD/Upper endoscopy o ERCP o Gallbladder o Hernia o Hemorrhoids o Hysterectomy o Liver biopsy o Obesity Surgery o Stomach o Knee/Hip Replacement o Metallic Valve Placement o NONE o Other surgery SOCIAL HISTORY: o Status o Single o Married o Domestic partnership o Divorced o Separated o Widowed o Race o Caucasian o African American o Hispanic/Latino o Asian o Other o Gender Male Female o Ethnicity If not American, o Smoker Pack Per Day Years o Non-Smoker o Alcohol o Socially o Regularly o Do Not Drink Amount per day o Caffeine o Yes o No Amount per day o Occupation o Working o Retired Sleep: o Difficulty Falling Asleep o Snoring o Daytime Drowsiness o Continuity Disturbances o Early Morning Awakening o Sleep Apnea o Other Blood Transfusion: o Yes o No Tattoos: o Yes o No Illicit Drugs: o Yes o No
3 FAMILY HISTORY: o Family history not known o Adopted Mother o Alive o Passed away o Colon cancer or polyps o Other Age: Father o Alive o Passed away o Colon cancer or polyps o Other Age: Sibling(s) o Alive o Passed away o Colon cancer or polyps o Other Age: Do you have a family history of colon cancer and/or polyps? o Yes o No If yes, who: Type of Cancer: Age Diagnosed: REVIEW OF SYSTEMS: Gastrointestinal tract: o Abdominal pain o Anal / Rectal pain o Belching o Black stools o Bloating o Blood in stool o Change in bowel habits o Constipation o Dairy intolerance o Diarrhea o Difficulty swallowing o Flatulence o Heartburn o Hemorrhoids o Mucous in stool o Nausea o Vomiting o Painful bowel movement o Rectal bleeding o Soiling stool / Incontinence o Weight Loss (unintentional) Cardiovascular: o Chest pain o Heart murmur o Palpitation o Shortness of breath Constitutional: o Chills o Fatigue o Fever o Loss of appetite o Night sweats o Weight gain o Weight loss Ear-Nose-Throat: o Hoarseness o Sore throat o Nose bleed Hematological: o Easy bruising o Prolonged bleeding o Swollen glands Respiratory: o Cough o Difficulty breathing Psychiatric: o Depression o Anxiety o Suicidal thoughts Genito-Urinary: o Pain with urination o Frequent urination o Urinary incontinence o Sexually Transmitted Disease o Blood in urine o Heavy menstruation Skin: o Dry skin o Itching o Rashes o Suspicious lesions Neurological: o Dizziness o Fainting spells o Frequent Headaches o Memory Disturbance o Numbness Endocrine: o Cold intolerance o Excessive thirst o Hair change Musculoskeletal: o Muscle ache o Back pain o Joint pain Signature
4 ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG HIPAA NOTICE OF PATIENT PRIVACY By my signature below I hereby acknowledge receipt of this Notice of Privacy Practices, and I acknowledge that the practice will use and disclose my health information for purposes of treatment, obtaining payment for services rendered to me, and conducting health care operations. I have also been advised of my rights to obtain access to and control my Protected Health Information AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Select ONE of the following options in case we need to contact to you about your health: I authorize the office to leave a message with detailed information regarding my health. OR I authorize the office to leave a message with a call-back number only, and wait for me to call to disclose any information regarding my health. Number you would like us to call regarding your health: Name of person or class of persons to whom the office may disclose my health information: Signature of Patient or of Personal Representative or parent/guardian
5 RECORD RELEASE AUTHORIZATION Patient's Name Address Date of Birth Signature Date I hereby authorize and request full release of my complete medical record to: Physician's Name: ALI S. KARAKURUM, M.D. FACP, FACG ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. Address: 70 N. Country Rd., Suite 201 Port Jefferson, NY Tel: (631) Fax: (631) Website:
6 Date ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. PATIENT NAME: ALI S. KARAKURUM, M.D., FACP, FACG 70 N. Country Rd., Suite Tel: (631) Port Jefferson, NY GASTRO-1 Fax: (631) Medications Dosage Frequency Start Date Stop Date PLEASE LIST ALL ALLERGIES:
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Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:
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GASTROENTEROLOGY HEPATOLOGY DIAGNOSTIC & THERAPEUTIC ENDOSCOPY
NORTON GASTROENTEROLOGY CONSULTANTS OF LOUISVILLE 3999 Dutchmans Lane, Medical Plaza 1, Suite 7B, Louisville, KY 40207 Phone: (502) 896-4711 Fax: (502) 896-4791 Website: www.nortongastrodocs.com GASTROENTEROLOGY
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
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Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
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Page1 Mala Bathija MD, PLLC 44000 West 12 Mile Road, Suite 212 Novi, MI 48377 14500 Northline Road Southgate,MI 48195 NEW PATIENT QUESTIONNAIRE Last Name First Name Phone # DOB Age Sex: M F Referring Physician
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
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Welcome to Midwest Gastrointestinal Associates, PC
Dear Patient: Welcome to Midwest Gastrointestinal Associates, PC An appointment has been scheduled for you on with Doctor at 8901 Indian Hills Drive, Suite 200 Omaha, NE 68114 Phone (402) 397-7057 Fax
PATIENT HISTORY FORM
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Vanessa Schulte, CCMA Practice Administrator Huntsville Hospital Pediatric Neurology
Kimberly L. Limbo, MD Kellie D. Anderson, CRNP Dear Parent, Thank you for choosing Huntsville Hospital Pediatric Neurology for your child s medical care. Our website should help answer any questions about