center for colorectal & pelvic health an affiliate of Welcome Back!

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1 center for colorectal & pelvic health an affiliate of Welcome Back! Many things have changed, and some have remained the same On behalf of Dr. Clifton L. Cox, we welcome you back to our practice. Since we have last seen you, many things have changed, but some have remained the same. We remain committed to our mission: We strive to provide compassionate, personalized, evidence-based treatment to maximize your colorectal and pelvic floor health. We are excited about the many changes to our practice, and look forward to hearing your comments on them. We are very proud of our new facility, which has been built expressly for the needs of our patients. For most, it is easier to get to, and the design is the culmination of 18 years experience in providing specialized care to colorectal and pelvic floor patients. We have renamed the practice to reflect the broader scope of services we provide. We are now the COPE Center for Colorectal and Pelvic Health, which reflects both the CO-lorectal and PE-lvic health aspects of our clinic. We can now provide under one roof a full range of diagnostic and treatment options to patients, including pelvic floor physical therapy, non-operative treatment of anorectal conditions, and more complex colon and pelvic floor surgical procedures. We will continue to do all outpatient surgery at Baylor Surgicare - Grapevine and the beautiful new private facility, Forest Park Medical Center in Southlake. We also perform more complex inpatient surgeries at Forest Park Medical Center as well as Baylor Regional Medical Center Grapevine. In order to make your time in the office as efficient as possible, we have enclosed a set of patient forms for you to update. Not only do these forms fulfill the regulatory requirements required to see you, they provide important clinical information that will optimize your care. We hope that by completing these forms in the comfort and privacy of your own home, you will take the time to answer as honestly and thoroughly as possible. Please bring the completed packet at least 10 minutes prior to your appointment, along with proof of insurance, a photo ID, a list of all the medications you are taking and any other information you feel may be pertinent. Cancellation or Rescheduling Appointments We are generally booked well in advance for all patient appointments. Please check all calendars to be sure your appointment date and time work. We ask that you notify us 24 hours in advance to cancel or reschedule an appointment. This will enable us to schedule someone else in that valuable time spot. Directions Our office is located at 300 S. Nolen Drive Suite 100 in Southlake, TX. From Hwy 114, Exit Kimball Avenue and turn South. Go to the next intersection, Southlake Blvd (FM 1709), and turn East (left) then turn South (right) at S. Nolen Dr. (Starbucks is on the corner). We are on the right hand side of the street. On Mapquest, you can find us at: On Google Maps the link is: We look forward to seeing you soon! (817) Fax (817) South Nolen Dr. Sui te 100 Southlake TX

2 center for colorectal & pelvic health an affiliate of Today s date Name of physician you are seeing today Last name of patient First name Middle Initial Street address City State ZIP Home Phone Mobile phone Work phone address Date of birth Age Sex Marital status Social security number Occupation Employed by Preferred method of contact (please circle one) Home phone Cell Work Portal Letter Declines to specify Emergency contact Home phone Referred by Primary insurance Relationship to patient Work phone Referring physician phone Insured name Relationship to patient Insured DOB Insured SSN ID# Group # Insurance phone Employer name Secondary insurance Insured name Relationship to patient Insured DOB Insured SSN ID# Group # Insurance phone Employer name I authorize the insurance listed above to pay directly to Texas Digestive Disease Consultants all benefits due me, as provided for in the above policy contract with the aforementioned company(ies). I will pay for all such charges that may be denied by the insurance company(ies) above mentioned. I hereby consent to receiving calls or texts on my mobile device. I have reviewed this office's notice of privacy practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. I hereby consent to treatment rendered by Texas Digestive Disease Consultants, which could include in office procedures and injections. Signature of Patient/Guardian/Personal Representative Name of Guardian/Personal Representative (please print) Date Relationship to patient

3 COPE Center for Colorectal and Pelvic Health an affiliate of Texas Digestive Disease Consultants Patient Interview Form First Name: Last Name: Account #: Date of Birth: Age: Gender: Reason for Today s visit: Current Other Physicians: Race: White/Caucasian Black/African American Asian Hispanic/Latino American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Mixed Other Unknown Patient declines to provide information Ethnicity: Hispanic or Latino Not Hispanic or Latino Patient declines to provide information Preferred Language: English Spanish Korean Contact Preference: Telephone call Allergies: Patient has no known allergies Patient has no known drug allergies Aspirin Codeine Demerol Fentanyl Flagyl Iodine IV Dye Levaquin/Cipro Morphine Penicillin Sulfa Versed Latex Eggs Shellfish Nuts Manifestations/Reactions: Immunizations/When?: Hepatitis B: Hepatitis A: Influenza: Pneumovax: Tetanus: Varicella/VZV: Current Medications: Name of Medication ( Ex: Nexium ) Dosage ( Ex: mg ) How often taken? ( Ex: 1 pill per day ) Vitamins, Herbal and Dietary Supplements: Pharmacy Name/Address/Phone/Fax Local and Mail Order:

4 Past Medical History: Cancers: Colon Esophageal Liver Small Intestine Stomach Kidney Pancreas Bladder Lymphoma Lung Skin Prostate Breast Cervical Ovarian Uterine Liver: Fatty liver Hepatitis A, Active Hepatitis B, Active Hepatitis C, Active Hepatitis, Autoimmune Digestive: Acid Reflux Barrett s Esophagus Celiac Sprue Cirrhosis of Liver Colon Polyps Crohn s Disease Diverticulitis ( Infected ) Diverticulosis H. Pylori Irritable Bowel Syndrome Pancreatitis Ulcer Ulcerative Colitis Miscellaneous: Anxiety/Panic Attacks Arthritis Asthma Atrial Fibrillation Congestive Heart Failure Coronary Artery Disease Depression Diabetes Emphysema Endometriosis Fibromyalgia Glaucoma Heart Attack High Blood Pressure High Cholesterol HIV Kidney Disease Lupus Osteopenia Osteoporosis Seizure Disorder Sleep Apnea Stroke/TIA Thyroid, Overactive Thyroid, Underactive Previous Gastroenterology Procedures: Colonoscopy EGD/Upper Endoscopy ERCP Endoscopic Ultrasound/EUS Small Bowel Capsule Surgical Procedures: Appendectomy C-Section Cataract Surgery Colon Resection Coronary Artery Bypass Coronary/Stent Defibrillator Gallbladder Removed Gastric Bypass Heart Valve Replacement/Repair Hemorrhoidectomy Hiatal Hernia Surgery ( for Reflux ) Hysterectomy, Partial ( Ovaries Intact ) Hysterectomy, Total ( Ovaries Removed ) Inguinal Hernia Surgery ( Groin) Joint Surgery/Replacement Lap Band Liver Transplant Mastectomy Pacemaker Prostatectomy Tonsillectomy Tubal Ligation Ulcer Surgery Umbilical Hernia Surgery ( Belly-Button ) Social History: Occupation: Marital Status: Single Married Divorced Separated Widowed Other Alcohol: Less than 7drinks per week More than 7 drinks per week I quit using alcohol Tobacco/Smoking Status: Current, every day smoker Current, some day smoker Former smoker Never smoked Smoker, current status unknown Unknown if ever smoked Chewing Tobacco/Snuff Cigar/Pipe Smoker Drug Use: I have used recreational drugs in the past I am currently using recreational drugs I have been treated for substance abuse Family Medical History: Unknown/Adopted No family history of colon cancer No family history of colon polyps Maternal Maternal Paternal Paternal Maternal Maternal Paternal Paternal Diagnosis Mother Father Sister Brother Daughter Son Grandmother Grandfather Grandmother Grandfather Aunt Uncle Aunt Uncle Other Age at Diagnosis Colon Cancer Colon Polyps Crohn s/colitis Liver Disease Uterine Cancer Kidney Cancer Stomach Cancer Bladder Cancer Pancreatic Cancer Ovarian Cancer

5 Review of Systems: Please indicate items you are CURRENTLY experiencing or if no symptoms exist: Gastrointestinal Cardiovascular Ear/Nose/Mouth/Throat Abdominal pain Heart murmur Double vision Anorectal pain/itching Irregular heart beat Eye irritation Black, tarry stools Hand/ankle swelling Eye pain Bloating/gas Rapid heart rate/palpitations Eye redness Blood in stool Chest pain Sore throat Change in bowel habits Hoarseness Constipation Mouth sores Diarrhea Neurological Nose bleeds Incontinence of stool Frequent headaches Post-nasal drip Heartburn/reflux Memory loss/confusion Recurrent sinus infections Difficulty swallowing Numbness or tingling Nausea Hematologic/Lymphatic Vomiting Anemia Endocrine Blood transfusions Genitourinary Cold intolerance Easy bruising Blood in urine Excessive thirst Prolonged bleeding Dark urine Heat intolerance Enlarged prostate Musculoskeletal Frequent urinary infections Back pain Heavy menstruation Constitutional Joint pain Pain/burning with urination Chills Pregnancy Fatigue Respiratory Sexually transmitted disease Fever Frequent cough Urinary incontinence Loss of appetite Shortness of breath Frequent urination Night sweats Snoring Weight gain Sleep apnea Integumentary/Skin Weight loss Wheezing Itching Jaundice Allergic/Immunologic Rashes Psychiatric Allergies Suspicious lesions Anxiety HIV exposure Bipolar disorder Immune deficiency Depression Reviewed with: Patient Parent Guardian Not present/telephone Signature: Date: