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English (US)
Spanish (Latin America)
Open Access Patient Interview Form
Northeast Digestive Health Center
Patient Information:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
County
*
The county you live in (NOT COUNTRY)
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Female
Male
Other
Race:
*
White/Caucasian
Black of 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
Ethnicity:
*
Hispanic or Latino
Not Hispanic or Latino
Patient declines to provide information
Preferred Language:
*
English
Spanish
Other
May we leave a detailed voicemail?
*
Yes
No
May we speak to someone else concerning your protected health information? If yes, please fill out the table below. Please note you are electronically consenting to releasing your protected health information to the person(s) listed below. In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications, or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.
*
Rows
First Name
Last Name
Relation
Phone Number
Contact 1
Contact 2
Insurance Information
Insurance:
*
Policy #:
*
Group Number:
*
Primary Insurance Co. Phone #:
*
Secondary Insurance: (If applicable)
Secondary Insurance Policy# and Group#:
Primary Care Physician:
*
Preferred Pharmacy:
*
Location of Pharmacy:
*
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Medical Information
Do you have any GI related concerns you would like to speak to a healthcare provider about?
*
Yes
No
If yes, briefly describe.
Height:
*
Feet & inches
Weight:
*
pounds
Allergies
*
Patient has no known allergies
Patient has no known drug allergies
Eggs
Soy
Latex
Fentanyl
Other
If you are allergic to anything above, what is your reaction?
MEDICATIONS
Current Medication(s) Please type none if you do NOT take any medications
*
Rows
Name of Medication
Dose
How Taken?
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Questions and Answers
(you must answer every question)
*
Rows
YES
NO
Are you 75 years or older?
Are you having any abdominal pain, constipation, diarrhea, heartburn or difficulty swallowing?
Are you on any blood thinners other than Aspirin?
Do you have a cardiac pacemaker?
Have you ever had stents placed in your heart?
Are you on dialysis or have a history of severe kidney disease?
Have you been diagnosed with congestive heart failure?
Have you ever had a heart attack?
Have you been diagnosed with COPD, Emphysema, use inhalers daily or have home oxygen?
Have you been diagnosed with diverticutlitis within the last 6 months?
Are you a diabetic on insulin?
Are you on any injectable medications for diabetes or weight loss?
Have you ever received a letter that you have a difficult airway?
Do you take narcotics or Methadone/Suboxone?
Have you been diagnosed with hemophilia?
Have you been diagnosed with sleep apnea?
Have you had a colonoscopy in the past?
Were polyps found in your prior colonoscopy (click No if this does not apply)?
Diagnostic Studies/Test
Have you had a previous colonoscopy?
*
Yes
No
If yes indicate date.
/
Month
/
Day
Year
Date
Do you have a history of colon cancer or colon polyps?
*
Yes
No
Not Sure/Unknown
Please provide name and location of doctor who performed previous colonoscopy.
Family Medical History:
Family Medical History:
Answer when applicable:
*
No knowledge of family history or I was adopted No family
No family history of Colon Cancer
No family history of Polyps
Family history of Polyps and/or Colon Cancer
Please indicate your family history below.
Rows
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Son
Daughter
Other
Bleeding Problem
Colon Polyps
Colon Cancer
Crohn's Disease
Inflammatory Bowel Disease
Ulcerative Colitis
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