Procedure Form PH5435 Patient Form2

User Manual: PH5435

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Patient Info-Edit
Med History-edit

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

Date:______________ Doctor:________________ Account:_______________

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:___________________

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 no

Are you a diabetic? yes no

If yes, controlled by: 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.

Choose Procedure

Colonoscopy

GHP Physician

Bizer

First

Last

2630 Grant Line Road

New Albany, IN 47150

PHONE812‐945‐0145 FAX812‐949‐5435 ACCOUNT#______________

LASTNAME: FIRSTNAME: MI:

ADDRESS:

CITY: STATE: ZIPCODE:

DATEOFBIRTH: SOCIALSECURITY#: SEX: MARITALSTATUS:

PHONENUMBERS:HOME WORK CELL

EMAILADDRESS: CANWECONTACTYOUBYEMAIL?

EMPLOYER:

SPOUSE/PARTNER: DATEOFBIRTH

EMERGENCYCONTACTNAME: RELATION: PHONE:

PRIMARYCAREPHYSICIAN: REFERRINGPHYSICIAN:

PRIMARYINSURANCE:

ADDRESS:

POLICYNUMBER: GROUPNUMBER:

PHONE: COPAY: EFFECTIVEDATE:

POLICYHOLDERNAME: DATEOFBIRTH:

EMPLOYER:

SECONDARYINSURANCE:

ADDRESS:

POLICYNUMBER: GROUPNUMBER:

PHONE: COPAY: EFFECTIVEDATE:

POLICYHOLDERNAME: 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

Female

Marital Status

Married

Patient Information Form

www.ghpsi.com

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

Mixed Other Unknown Patient declines

to provide

information

Prohibited by

state law

Ethnicity

Hispanic or

Latino Not Hispanic or

Latino Patient declines

to provide

information

Prohibited by

state law

Preferred Language

Other:

Allergies

Patient has no known allergies Patient has no known drug allergies

Aspirin Iodine Penicillins Sulfa

(Sulfonamides) Versed

Dairy products Latex codeine sulfate Other:

Current Medications

None

Name Dose How taken?

Page 1 of 5

Gastroenterology

HEALTH PARTNERS

2630 Grant Line Road

New Albany, IN 47150

(812) 945-0145

Pharmacy

Name:

Social History

Occupation: Number of Children:

Marital Status

Single Married Divorced Separated Widowed

Civil Union Unknown Other

Alcohol

None

Type Quantity Frequency

Alcoholic Drink Times / week

Caffeine

None

Tobacco

Smoking Status Current every

day smoker Current some

day smoker Former smoker Never smoker

Smoker, current

status unknown Unknown if ever

smoked

Type Started Quit Quantity Frequency

Cigarettes Cigarettes / Day

Drug Use

None

Type Quantity Frequency

Recreational Drugs 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

Replacement Kidney Liver Biopsy Obesity Surgery Ovary surgery

Pacemaker/Defibrillato

Prostate

Surgery Radiation

Therapy-

Abdomen

Radiation

Therapy-Chest Radiation

Therapy-

Head/Neck

Radiation

Therapy-Ovary Radiation

Therapy-

Prostate

Stomach Thyroid Tubal Ligation

Upper/EGD Heart Stent

Placement Artificial Heart

Valve Dialysis Other:

Page 2 of 5

Past or Present Medical Conditions

None

GI Related Illnesses Cirrhosis Colon polyps Crohn's Disease Diverticulitis

Esophagitis/GERD Gallstones Groin Hernia Hepatitis

Irritable Bowel Pancreatitis Stomach/Duodenum

Ulcer Ulcerative Colitis

Other:

Other Illnesses Abnormal

Bleeding Abnormal Blood

Clotting/Blood

Clots

Anemia Arterial

Blockages

Asthma Blood

Transfusions Breast cancer Chronic

Headache

Chronic Pain for

less than 6

months

Colon cancer Diabetes

Mellitus Emphysema

Endometriosis Fibromyalgia Frequent

Urinary

Infections

Heart Disease

Heart Failure Heart Murmurs High Blood

Pressure High

Chlolesterol

HIV/AIDS Irregular Heart

Beat Kidney

Disease/Failure kidney stones

Lupus Melanoma Multiple

Sclerosis Osteoporosis

Ovarian Cancer Ovarian Cyst Parkinson's

Disease Pneumonia

Prostate Cancer Psoriasis Rheumatic

Fever Seizures

Sexually

Transmitted

Disease

Sleep apnea Stroke or

Paralysis TB or Positive

TB Skin Test

Thyroid Disease Deep vein

thrombosis

(blood clot in

leg)

Pulmonary

embolus (blood

clot in lung)

CVA (stroke)

TIA Other:

Diagnostic Studies/Tests

None

Labs

When: Xray/Radiology

When:

Page 3 of 5

Immunizations

None

Flu vaccine Hepatitis A Hepatitis B HPV Meningococcal

Pneumoccocal Tdap

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

aundice

rash

suspicious lesions

Musculoskeletal

back pain

oint 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

Procedure Form PH5435 Patient Form2

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