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Transcription:

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 70503 337-232-6697 FAX: 337-232-3147 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Email Please check one as your preferred email 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

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

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

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

Page 6 of 6 Signature Signature Date

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