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. Clark, MD Paul B. Lamb, MD Scott A. Sarrels, MD Tyler P. Black, MD George A. Nelson, IV, MD Pathologist: Beth Rutland, MD 334-836-1212 phone 334-836-1888 fax 480 Honeysuckle Rd, Dothan, AL 36305 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Personal: Race Select one or more White Black or African American Asian Other Race Unknown Patient declines American Indian or Alaska Native Prohibited by state law Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino t Hispanic or Latino Patient declines Prohibited by state law Unknown Sex Male Female Other Preferred Language English Patient declines Contact Preference Letter Telephone call e-mail Cell Phone Patient declines Reminder Preference I would like to receive preventive care and follow up care reminders.
Page 2 of 5 Consent to Share Data I consent to having my medical and demographic information shared with other health care entities. Allergies Patient has no known allergies Patient has no known drug allergies Demerol IVP Dye Penicillins Propofol Codeine Sulfate Lortab Ambien Latex Versed Sulfa (Sulfonamide Antibiotics) Immunizations ne Flu Vaccine Hep B PPD/TB Skin Test Pneumonia Vaccine Pharmacy Name Address Phone Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Current Medications ne Name Dose How taken?
Page 3 of 5 Diagnostic Studies/Tests ne Abdominal Ultrasound Barium Swallow Colonoscopy CT Abdomen HIDA Scan Sigmoidoscopy Test for Blood in Stool Upper Endoscopy/EGD Esophageal Motility Study Previous Procedures ne Appendectomy/Appendix Gastric Bypass Hysterectomy Heart Bypass Pacemaker Cholecystectomy/Gallbladder Heart Valve Replacement Paracentesis Colon Surgery Hemorrhoid Surgery Prostate Surgery Defibrillator Hernia Repair Past or Present Medical Conditions ne Anemia Anxiety/Depression Arthritis Atrial Fibrillation Barrett's Esophagus Bleeding Disorders Colon Polyps Blood Clots (DVT) Congestive Heart Failure Cancer Celiac Disease Cirrhosis Crohn's Disease Diverticulitis/Diverticulosis Gallstones GERD or reflux disease Hemorrhoids Hepatitis C High Blood Pressure Diabetes (Insulin Dependent) Kidney Dialysis Liver Disease Pancreatitis Pulmonary Embolism HIV GI Bleeding Stroke Ulcer Disease Ulcerative Colitis Diabetes (n Insulin Dependent) Irritable Bowel Syndrome Heart Attack Seizure Disorder Social History Occupation: Marital Status Single Married Divorced Separated Widowed Alcohol ne Caffeine Intake: ne
Page 4 of 5 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 ne Exercise ne Review Of Systems Constitutional ne chronic fatigue fever weight loss Integumentary ne bruising rash Hematologic/Lymphatic ne anemia blood disorders easy bleeding Musculoskeletal ne weakness back pain joint pain ENMT ne deafness dizziness mouth or throat sores hoarseness Respiratory ne asthma wheezing cough shortness of breath Cardiovascular ne chest pain palpitations Gastrointestinal ne diarrhea constipation heartburn stomach cramps nausea vomiting blood in stool blood on the tissue paper bloating jaundice gas trouble swallowing abdominal pain Genitourinary ne increased urinary frequency change in urine color prostate problems Neurological ne stroke numbness Psychiatric ne bad nerves depression
Page 5 of 5 Family Medical History knowledge of family history family history of Colon Polyps Health Status Cause of Death Diagnoses Gallstones Pancreas problems Liver disease Colon polyps Colon cancer Crohn's disease Ulcerative colitis Stomach ulcers Health Status Cause of Death Diagnoses Gallstones Pancreas problems Liver disease Colon polyps Colon cancer Crohn's disease Ulcerative colitis Stomach ulcers