Patient Interview Form
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1 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, LA FAX: Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Please check one as your preferred for communications Personal: Work: Preferred Language English French Patient declines Contact Preference Patient Portal Home Number Cell Phone May leave a message on machine Patient declines All of the Above Ethnicity Hispanic or Latino Not Hispanic or Latino Patient declines Sex Male Female Other Race Select one or more White Unknown Black or African American Patient declines Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Pharmacy Name Address Phone Allergies Patient has no known allergies Patient has no known drug allergies Drug Allergies: Aspirin Codeine Iodine Penicillins
2 Page 2 of 6 Sulfa Latex Surgical Tape Current Medications Name Dose How taken? Immunizations Flu Vaccine Hepatitis B Hepatitis A Pneumonia Shingles Diagnostic Studies/Tests Colonoscopy EGD Past or Present Medical Conditions Anemia Autoimmune Disease Fatty liver Cirrhosis, Liver Hepatitis A Hepatitis B Hepatitis C HIV Barrett's Esophagus GERD Gastric Ulcer Trouble swallowing History colon polyps History of Colon Cancer Crohn's Disease Ulcerative Colitis Celiac Disease Pancreatitis Gallbladder Disease Diverticular Disease Other Medical Conditions: Asthma Sleep apnea C.O.P.D. Home oxygen Emphysema Blood thinners Congestive Heart Failure Hypertensioncontrolled by medication Hypertension uncontrolled by medication Artificial Heart Valve Tuberculosis, Exposure Glaucoma Pacemaker/ Defibrillator Kidney disease Diabetes Mellitus HX of Cancer Previous Heart Attack Dialysis High cholesterol Rheumatoid Arthritis Stroke Seizures Mitral Valve Prolapse/MR Previous Procedures
3 Page 3 of 6 Nissen Fundoplication Gastric By-Pass Hernia Repair Appendectomy Gallbladder Surgery Colon Resection Other Surgical Procedures: C-Section Joint Replacement Hysterectomy Heart stents Open heart surgery Social History Number of Children: Marital Status Single Married Divorced Widowed Other Alcohol Type Quantity Frequency Beer Hard liquor Wine Caffeine Coffee Energy Drinks Soda Tea Other 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 Drug Use IV Drugs Other Exercise Daily 1-3 times per week 4-6 times per week Rarely
4 Page 4 of 6 Family Medical History No knowledge of family history No family history of Colon Cancer Colon Polyps Crohn's Disease Gallbladder Disease Diagnoses Esophageal Cancer Stomach Cancer Colon Cancer Colon Polyps Inflammatory Bowel Disease Celiac Disease Diabetes Breast Cancer Endometrial/Ovarian Cancer Gallbladder Disease Heart Disease/Hypertension Stroke Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Yes No Consent to Share Data I consent to having my medical and demographic information shared with other health care entities. Yes No Reminder Preference I would like to receive preventive care and follow up care reminders. Yes No Reviewed with Patient Parent Guardian Not Present
5
6 Page 6 of 6 Signature Signature Date
Patient Interview Form
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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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 Unknown
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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
More informationModesto Gastroenterology Medical Corporation
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 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 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 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 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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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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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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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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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 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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Telephone: 703-698-8960 Fax: 703-828-0961 www.myganv.com Patient Interview Form Patient Information First Name: Last Name: Date Of Birth: Age: Height: Weight: Race Select one or more White Unknown Black
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First Middle Last Mailing Address: Primary Phone: Street City Zip Secondary Phone: Date of Birth: Male Female SSN: Emergency Contact Phone: Marital Status: Single Race: American Indian or Alaska Native
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KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM Dr. Mr. Mrs. Ms. Miss New Patient or Returning Patient FULL LEGAL NAME: Reason for today s visit: Mohs Excision Skin Check other:
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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
More information*** ADDRESS: (If address is not provided, you MUST write Patient denied.)
PATIENT INFORMATION NORTHWEST BROWARD ORTHOPAEDICS DATE: ***E-MAIL ADDRESS: (If e-mail address is not provided, you MUST write Patient denied.) Pharmacy Name: Pharmacy Phone Number: Pharmacy Location PATIENT
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Page 1 of 7 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Contact Preference Email Cell phone Telephone call- Work Telephone call - Home Patient Portal Email Please
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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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DEMOGRAPHICS Date of Birth: Age: years Gender: Male Height: inches Female Weight: lbs Handed: Right BMI: Left Ambidextrous Race: choose only one Ethnicity: Marital Status: African American / African Heritage
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