New Patient Information Packet
Please:
1) Review “Payment Terms and Agreements”, “Notices of Privacy Practices for Protected Health Information” and “Online Communications Policy” located on this website
2) Print the 2nd and 3rd pages of this packet to fill out
3) Sign the following Consent/Signature sheet and the New Patient History form
4) Arrive 10 minutes prior to your scheduled appointment
5) Call at least 24 hours in advance if you need to cancel or reschedule
6) Be sure to bring both the Consent/Signature sheet and New Patient History form with you to your appointment.
7) You will also need to bring your insurance card, any applicable co-pay and a photo ID.
Summit Gastroenterology
Patient Consent, Contact and Signature sheet
PLEASE PRINT:
Patient Name: ______Date of Birth: ______
Social Security #: ______
Present Address: ______Apartment #: ______
City ______State ______Zip ______
Telephone (#1) ______This is how we will contact you to provide results and appointment reminders
(#2) ______This is our backup number to reach you
Primary Language______
Race ______Ethnicity ______
………………………………………………………………………………………………………………………
In case of emergency please notify:
Emergency contact name ______Relation ______
Telephone ______
………………………………………………………………………………………………………………………
*PLEASE PROVIDE YOUR INSURANCE CARD AND PHOTO ID TO THE RECEPTIONIST
NAME OF PRIMARY INSURED (if different from above) ______
SS# OF PRIMARY HOLDER (if different) ______DOB OF PRIMARY HOLDER ______
RELATIONSHIP TO PATIENT ______
………………………………………………………………………………………………………………………
(Please review the Patient Information Packet before signing below. Please note that we will leave normal lab or test results on your answering machine unless you specifically ask us not to)
1) I have reviewed the document, “PAYMENT TERMS AND AGREEMENTS, V 2/11/2011” and my
signature here indicates that I agree to the terms set forth: X______
Signature of patient or patient representative
2) I have reviewed the document, “Notice of Privacy Practices for Protected Health Information”:
X______
Signature of patient or patient representative
3) I authorize the exchange of pharmacy information between my pharmacy and Dr. Aaron Burrows, MD P.C.:
X______
Signature of patient or patient representative
4) I have reviewed the “Online Communications Informed Consent” and “Patient Portal Info”:
X______
Signature of patient or patient representative
My email address is: ______(This allows us to notify you of test results and allows you access to the patient portal.)
CONFIDENTIAL PATIENT INFORMATION
Your Name: Your Age: / Patient barcode goes here(do not write in this section)
Your Referring Doctor:
What is your Chief Complaint?
Regarding this illness, do you have or have you had: Abdominal pain Heartburn/reflux Nausea Vomiting Blood in vomit Difficulty swallowing Loss of Appetite Constipation Diarrhea Fever Red Blood in stool Black/tarry stools Unintended weight loss Regurgitation of food Yellow skin/eyes
Have you ever had a COLONOSCOPY: Yes -when?______No
Have you ever had an Upper Endoscopy (EGD) : Yes- when?______No
Please list your past medical history:
Please list all your previous surgeries (and approximate dates):
Please list all your current medications. Include birth control, aspirin, over-the-counter, or homeopathic medicines:
Drug allergies and type of reaction:
Which Vaccinations have you had?: □Hepatitis A-Year completed: □Hepatitis B-Year completed:
Family Health (please list any health problems or cancers for your immediate family):
Mother: Father: Siblings: Grandparents:
Is there a history of colon polyps in your family? Yes No I don’t know
Smoking? Yes No Former
How many years did you smoke? :______How Much?: ______/ Recreational Drugs? Yes No Type:______
Alcohol? None Occasional Moderate Heavy
Occupation: / Caffeine use: None Moderate Heavy / Diet: Regular Vegetarian
Sexual History: Sexually active? Yes No Heterosexual Homosexual Bisexual
Your Height: ______Weight: ______
Review of Systems (Please circle only those conditions below that you have or have had in the past)
Constitutional: Fatigue Fever Night sweats Weight gain (______lbs) Weight loss (______lbs)
Hearing loss Nose bleeds Sinus Problems Sore throat Bleeding gums Snoring Mouth ulcers
Cardiac: Chest Pain/Pressure Arm pain on exertion Shortness of breath Palpitations Heart Murmur Angina /Heart Attack Heart valve infection CHF Leg Edema Abnormal EKG
Respiratory: Cough Wheezing Shortness of breath Asthma COPD/Emphysema
Digestive: Abdominal pain Vomiting Change of Appetite Black or tarry stools Celiac Sprue/Gluten sens Lactose Intolerance Hepatitis C Hemorrhoids Diverticulosis Hiatal Hernia Ulcers Pancreas problems Liver disease Gallbladder problems Inflammatory Bowel Disease Irritable Bowel Syndrome GI Cancers:______ Sensitivities to foods ______ Infection Fatty Liver Reflux/GERD Colitis
Urinary: Urinary loss of control Difficulty urinating Urinary frequency Incomplete emptying Kidney Stones Urinary Infections Chronic Kidney Disease
Muscles/Bones: Muscle aches/weakness Joint pain Back pain Osteoporosis
Neuro: Loss of consciousness Weakness Numbness Seizures Dizziness Headaches Stroke Multiple Sclerosis
Psychiatric: Depression Anxiety Mania Sleep disturbances Feeling unsafe in a relationship Alcohol abuse Schizophrenia Anorexia Bulemia
Endocrinology: Increased thirst Hair falling out Increased hair growth Chronically tired Thyroid Disease Pituitary Problems Adrenal Problems Reproductive Problems Diabetes
Hematology: Swollen glands Bruising Bleeding problems Anemia (low red blood cell count) Low platelets High/low white blood cells Blood Cancers HIV+ Blood transfusions STD
Skin/Allergy: Skin rashes Jaundice Eczema Bruising Itching Hives Sneezing