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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