SAMEER ISLAM, MD, MBA
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- Virgil Carroll
- 5 years ago
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1 ` SAMEER ISLAM, MD, MBA Greetings, Before your upcoming appointment, I want to say thank you for allowing me the privilege of taking care of you. Our clinic is committed to providing compassionate and quality care. It is our priority to establish a relationship with our patients and also include them in their treatment plan. I know any healthcare related appointment can invite fear. Because of this, I want to begin by sharing information with you about myself before we start our journey together. I grew up in Odessa, Texas and completed my undergraduate degree at the University of Texas in Austin, graduating with honors. I received my Doctorate in Medicine (MD) and Masters of Business Administration (MBA) at Texas Tech University Health Sciences Center and Texas Tech Rawls School of Business, respectively. I continued my fellowship training in Gastroenterology at Mayo Clinic where I was promoted to the academic rank of Assistant Professor of Medicine. In my free time, I love reading, writing, workout out, and spending time with my beautiful wife and children. If you would like to find out more about me and my interests, please take a look at the links below! You may see some pictures of my crazy socks and my bowties. I would encourage you to sign up for my newsletter. I will send you information about your visit and updates on various gastrointestinal conditions. Every Wednesday at 8:30 PM, I also host a Facebook Live program- come watch and learn! Social Media Links: Blog: Weight loss: Facebook: Twitter: I know you have many medical options here in West Texas, so I appreciate you trusting me with your healthcare needs. We are proud of the highly qualified and dedicated professional staff and their commitment to restoring health, promoting wellness, and providing comfort in a positive, caring environment. I strive to earn your trust and provide you with excellent care. You may receive a satisfaction survey by mail or after your visit. Please take time to complete our survey. Your feedback is how we recognize our staff and improve the healthcare process. Thank you for allowing me to take care of you! Sincerely, Sameer Islam, MD
2 UMC Southwest Gastroenterology Joseph E. Hancock, M.D./R. Sameer Islam, M.D./Vanessa Costilla, M.D. Gastroenterology and Liver Disease th Street Suite 360 * Lubbock, Texas Office (806) Fax (806) Board Certified Internal Medicine Board Certified in Gastroenterology Date: Name: DOB: Reason for Visit: ALLERGIES: CIRCLE THOSE THAT APPLY AND EXPLAIN: ABDOMINAL PAIN APPETITE CHANGES FEVER ANEMIA REGURGITATION HEARTBURN VOMITING BLOATING DIARRHEA NAUSEA GALLSTONES POLYPS CONSTIPATION WEIGHT LOSS SWALLOWING JAUNDICE EXPLAIN: HAVE YOU EVER HAD A COLONOSCOPY? YES NO IF YES, WHEN AND WHERE: DO YOU HAVE A HISTORY OF COLON POLYPS? YES NO IF YES, HOW MANY: FAMILY HISTORY OF COLON CANCER? YES NO IF YES, WHO DO YOU HAVE HEMORRHOIDS? YES NO IF YES DO THEY BOTHER YOU NOW? YES NO DO YOU HAVE ACID REFLUX (GERD)? YES NO IF YES IS IT CONTROLED BY MEDS? YES NO DIARRHEA? WATER BLOODY PUS MUCOUS FREQUENCY EXPLAIN: HAVE YOU EVER BEEN DIAGNOSED WITH HEPATITIS? YES NO IF YES, WHICH TYPE: IV DRUG USE: YES NO IF YES WHEN: HOW LONG: ALCOHOL USE: YES NO IF YES HOW MUCH: HOW LONG: TOBACCO USE: YES NO IF YES HOW MUCH: HOW LONG: MARRIED SINGLE DIVORCED NUMBER OF CHILDREN: OCCUPATION: EDUCATION:
3 MEDICAL CONDITIONS: DIABETES HYPERTENSION CANCER HEART DISEASE THYROID DISEASE KIDNEY DISEASE OTHER: MEDICATIONS: HOSPITALIZATIONS/SURGERIES: YEAR REASON YEAR REASON FAMILY HISTORY: ANEMIA ARTHRITIS ASTHMA CELIAC DISEASE COLON CANCER CROHNS DIABETES EPILIPSY HEART DISEASE HYPERTENSION KIDNEY DISEASE LIVER DISEASE PANCREATITIS ULCERS STROKE TUBERCULOSIS ULCERATIVE COLITIS REVIEW OF SYSTEMS: (PLEASE CIRCLE IF IT APPLIES TO YOU) GENERAL: FEVER CHILLS WT. LOSS FATIGUE EYES: YELLOW EYES VISION CHANGES BLURRY PAIN EARS: HEARING LOSS VERTIGO PAIN NOSE: BLEEDING LOSS OF SMELL CONGESTION THROAT: HOARSNESS LOSS OF SPEECH PAIN WHILE SWALLOWING RESPIRATORY: COUGH WHEEZING SHORTNESS OF BREATH SPUTUM HEART: CHEST PAIN VASCULAR: LEG PAIN LEG SWELLING CLOTS GENITOURINARY: BURNING DURING URINATION BLOOD IN URINE ENDOCRINE: HEAT/COLD INTOLERANCE NEURO: LOSS OF CONSCIOUSNESS ABNORMAL BALANCE HEADACHES MUSCOSKELETAL: JOINT PAIN NECK/BACK PAIN PSYCH: ANXIETY DEPRESSION HALLUCINATIONS CANCER:
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QUESTIONNAIRE Page 1 of 5 Date: Referring MD (Name, Address, Phone Number): Primary Care Physician (Name and Address, Phone Number): Reason for visit: 1. How long have you had symptoms? Describe your symptoms?
PLEASE COMPLETE ALL SECTIONS OF THIS FORM
PLEASE COMPLETE ALL SECTIONS OF THIS FORM Patient Name: Date of Birth: Referring Doctor? (Name, telephone number and address) Chief Complaint: Why have you come here? How did it start? What are the symptoms?
New Patient Information Form
New Patient Information Form Patient Label Dear Patient: Please take a few minutes to complete this form. Your answers will help the doctors and staff plan and provide your care. If you are unsure of any
Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX Phone (903) Fax (903)
Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX 75460 Phone (903) 905-4609 Fax (903) 905-4611 Enclosed are forms for you to complete prior to your appointment. Please bring these completed
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your