Procedure Form PH5435 Patient Form2

User Manual: PH5435

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2630 Grant Line Road
New Albany, IN 47150
812-945-0145 ph
812-949-5435 fx

Thank you for choosing Gastroenterology Health Partners
for your digestive health. Please complete the three
attached forms and then either:
1. Print them off and bring with you to your appointment
2. Print them off and f ax them to the appropriate number at
left
3. E-mail these forms to Alicia Prince at
APrince@ghpsi.com
If you have any questions, please feel free to call
812-945-0145.
Thank you for helping be ecologically conscious by being
paperless.

Procedure Scheduling Form Choose Procedure
Colonoscopy
GHP Physician
Date:______________
Doctor:________________
Account:_______________
Bizer
Please fill in all information listed below to assure your appointment is scheduled for your convenience
and all major health issues are taken into consideration for safety of your preparation prior to the
procedure.
YOU ARE SEDATED FOR THESE PROCEDURES AND WILL NEED SOMEONE TO DRIVE YOU
HOME AFTERWARD.
Patient:___________________________________
DOB:___________________
First
Last
Procedure will be performed at Physicians Medical Center
unless we do not participate with your insurance plan.
Schedule procedure on:

Monday

Tuesday

Wednesday

Thursday

Friday

Any

Is there any specific date(s) good for you? ____________________________________
Is there any specific date(s) not good for you? _________________________________
Are you allergic to latex?

yes

Are you a diabetic?
yes
If yes, controlled by:

no
no
Diet
Medicine
Name: _______________________________________
Dosage_______________________________________
Insulin - dosage_______________________________________

Do you take medications for:

Arthritis ____________________________
Heart disease ________________________
Blood thinner ________________________

Do you have an artificial heart valve?
yes
no
If yes, do you receive antibiotics prior to dental work or surgery?

yes

no

Do you have a pacemaker?
Yes
no
If yes, list brand and model________________________________________________
Do you have a personal history of cancer?

Yes

no

Who/Type__________________

Please be aware that if a procedure needs to be rescheduled it could take up to 4-6 weeks depending on
the physicians’ schedules. We appreciate and encourage that you make every effort to keep your
appointment.

Patient Information Form
www.ghpsi.com

Gastroenterology

2630 Grant Line Road

HEALTH PARTNERS

PHONE 812‐945‐0145 FAX 812‐949‐5435

New Albany, IN 47150

LAST NAME:

ACCOUNT #______________

FIRST NAME:

MI:

ADDRESS:
CITY:
DATE OF BIRTH:

STATE:

ZIP CODE:
SEX: Female
MARITAL STATUS: Marital

SOCIAL SECURITY #:

PHONE NUMBERS: HOME

WORK

CELL

EMAIL ADDRESS:

CAN WE CONTACT YOU BY EMAIL?

Status
Married

EMPLOYER:
SPOUSE/PARTNER:

DATE OF BIRTH

EMERGENCY CONTACT NAME:

RELATION:

PHONE:

PRIMARY CARE PHYSICIAN:

REFERRING PHYSICIAN:

PRIMARY INSURANCE:
ADDRESS:
POLICY NUMBER:
PHONE:

GROUP NUMBER:
COPAY:

POLICY HOLDER NAME:

EFFECTIVE DATE:
DATE OF BIRTH:

EMPLOYER:

SECONDARY INSURANCE:
ADDRESS:
POLICY NUMBER:
PHONE:
POLICY HOLDER NAME:

GROUP NUMBER:
COPAY:

EFFECTIVE DATE:
DATE OF BIRTH:

EMPLOYER:

INSURANCE AUTHORIZATION:
I request that payment of authorized benefits be made either to me or on my behalf to the above provider for services furnished
by that physician. I authorize release to the indicated insurance carrier any medical information about me needed to determine
these payments for related services. I understand that I am responsible for all fees regardless of insurance.

SIGNATURE:

DATE:

Gastroenterology
HEALTH PARTNERS

2630 Grant Line Road
New Albany, IN 47150
(812) 945-0145

Patient Interview Form
Patient Information
First Name:

Last Name:

MRN:

Date Of Birth:

Race
White/Caucasian

Black or African
American

Asian

Hispanic or
Latino

American Indian
or Alaska Native

Native Hawaiian
or Other Pacific
Islander
Prohibited by
state law

Mixed

Other

Unknown

Patient declines
to provide
information

Not Hispanic or
Latino

Patient declines
to provide
information

Prohibited by
state law

Ethnicity
Hispanic or
Latino

Preferred Language
Other:

Allergies
Patient has no known allergies

Patient has no known drug allergies

Aspirin

Iodine

Penicillins

Dairy products

Latex

codeine sulfate

Sulfa
(Sulfonamides)
Other:

Versed

Current Medications
None
Name

Dose

How taken?

Page 1 of 5

Pharmacy
Name:

Social History
Occupation:

Number of Children:

Marital Status
Single

Married

Divorced

Civil Union

Unknown

Other

Separated

Widowed

Alcohol
None
Type
Alcoholic Drink

Quantity

Frequency
Times / week

Caffeine
None

Tobacco
Smoking Status

Current every
day smoker

Current some
day smoker

Smoker, current
status unknown

Unknown if ever
smoked

Type
Cigarettes

Started

Quit

Former smoker

Never smoker

Quantity

Frequency
Cigarettes / Day

Drug Use
None
Type
Recreational Drugs

Quantity

Frequency
Times / week

Exercise
None

Previous Procedures
None
Appendectomy

Capsule
Endoscopy

Cardiac (CABG)

Cardiac (VALVE)

Colon Polyp
Removal

Colon Resection

Colonoscopy

Colostomy

C-Section

ERCP

Gallbladder

Groin Hernia

Hemorrhoid

Hiatal Hernia

Hysterectomy

Joint
Kidney
Replacement
Pacemaker/Defibrillator
Prostate
Surgery

Liver Biopsy

Obesity Surgery

Ovary surgery

Radiation
Therapy-Ovary

Stomach

Thyroid

Artificial Heart
Valve

Dialysis

Upper/EGD

Radiation
TherapyProstate
Heart Stent
Placement

Radiation
TherapyAbdomen

Radiation
Therapy-Chest

Radiation
TherapyHead/Neck
Tubal Ligation

Other:

Page 2 of 5

Past or Present Medical Conditions
None
GI Related Illnesses

Cirrhosis
Esophagitis/GERD
Irritable Bowel

Colon polyps

Crohn's Disease

Gallstones

Groin Hernia

Diverticulitis
Hepatitis

Pancreatitis

Stomach/Duodenum
Ulcer

Ulcerative Colitis

Abnormal Blood
Clotting/Blood
Clots
Blood
Transfusions

Anemia

Arterial
Blockages

Breast cancer

Chronic
Headache

Chronic Pain for
less than 6
months
Endometriosis

Colon cancer

Diabetes
Mellitus

Emphysema

Fibromyalgia

Frequent
Urinary
Infections

Heart Disease

Heart Failure

Heart Murmurs

HIV/AIDS

Irregular Heart
Beat

High Blood
Pressure
Kidney
Disease/Failure

High
Chlolesterol
kidney stones

Lupus

Melanoma

Osteoporosis

Ovarian Cancer

Ovarian Cyst

Multiple
Sclerosis
Parkinson's
Disease

Prostate Cancer

Psoriasis

Seizures

Sexually
Transmitted
Disease

Sleep apnea

Rheumatic
Fever
Stroke or
Paralysis
Pulmonary
embolus (blood
clot in lung)

CVA (stroke)

Other:
Other Illnesses

Abnormal
Bleeding
Asthma

Thyroid Disease

TIA

Deep vein
thrombosis
(blood clot in
leg)
Other:

Pneumonia

TB or Positive
TB Skin Test

Diagnostic Studies/Tests
None
Labs
When:

Xray/Radiology
When:

Page 3 of 5

Immunizations
None
Flu vaccine

Hepatitis A

Pneumoccocal

Tdap

Hepatitis B

HPV

Meningococcal

Family Medical History
No knowledge of family history
No family history of

Colon cancer

Colon Polyps

Health Status
Age/Date of Birth
Family Hx of Colon Cancer
Family Hx of Colon Polyps
Family Hx of Celiac Disease
Family Hx of Colitis
Family Hx of Crohn's Disease
Family Hx of Liver Disease
Family Hx of Breast Cancer
Family Hx of Esophageal Cancer
Family Hx of Ovarian Cancer
Family Hx of Pancreatic Cancer
Family Hx of Stomach Cancer
Family Hx of Uterine Cancer

Page 4 of 5

Review Of Systems
Cardiovascular
ankle swelling
chest pain
irregular heart beat
shortness of breath
Constitutional
fatigue
fever
loss of appetite
weight loss
weight gain
ENMT
hearing loss
hoarseness
sore throat
nose bleeds
Endocrine
excessive thirst
cold intolerance
heat intolerance
Eyes
light sensitivity
eye pain
visual decline
Gastrointestinal
abdominal pain
belching
black stools
bloating
change in bowel habits
constipation
dairy incontinence
diarrhea
difficulty swallowing
painful swallowing
flatulence/rectal gas
heartburn/reflux
mucous in stools
nausea
painful stools
rectal protusions
rectal urgency

Genitourinary
blood in urine
burning urination
Hematologic/Lymphatic
easy bruising
prolonged bleeding
abnormal blood clotting
Integumentary
itching
jaundice
rash
suspicious lesions
Musculoskeletal
back pain
joint pain
muscle pain
Neurological
dizziness
fainting
frequent headaches
loss of consciousness
Psychiatric
anxiety/panic
depression
difficulty sleeping
Respiratory
coughing blood
chronic cough
painful breathing

soiling/incontinence
vomiting

Page 5 of 5



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