Registration & HPI General Surgery for Dr. Kukreja, Dr. Hooper, and Dr. Barr

  • Patient History and Intake for General Surgery

  • PLEASE NOTE, ALL FIELDS WITH A RED STAR ARE REQUIRED. THE FORM WILL NOT SUBMIT UNLESS THOSE FIELDS ARE COMPLETED!

    • Patient Information 
    • Sex*
    • Ethnicity*
    • Race*

    •  -
    •  -
    •  -
    • Okay to add you to our mailing list?
    • Pharmacy Information 
    •  -
    •  -
    • Primary Insurance 
    • Are you using insurance or self paying for our services?*
    •  -
    •  -
    • Who is the primary insured party?

    •  -
    •  -
    •  -
    • Patient's Relation to Insured Party

    • Secondary Insurance 
    • Do you have secondary insurance?
    •  -
    •  -
    • Who is the secondary insured party?

    •  -
    •  -
    •  -
    • Patient's Relation to Insured Party

    • Medicare 
    • Do you have Medicare?
    • Are you a resident at:
    • Admit Date
       - -
    •  -
    • Authorization and Acknowledgement 

    • Please list the people with whom we can discuss your care and leave messages.

    •  -
    •  -
    • May we leave messages on your answering machine regarding your care? (Please understand that if we cannot leave messages, it is your responsibility to initiate contact with us regarding follow-up of labs, appointment, etc.)
    • Release of Medical Records 
    • Notice of Privacy Practices 
    • Authorization List - Do you have anyone you want to receive information from our office, on your behalf?*

    • The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for DFW Bariatrics and General Surgery to share my protected health information with:

    • Your Doctors 

    • Please let us know of all the doctors you see.

    • Primary Care Doctor*
    •  -
    • Referring Doctor
    •  -
    • Cardiologist
    •  -
    • Gastroenterologist
    •  -
    • Pulmonologist
    •  -
    • Orthopedic Surgeon
    •  -
    • History 
    • Sleep History 
    • Have you been diagnosed with SLEEP APNEA SYNDROME?*
    • Rows
    • Do you have or have you ever had: (check all that apply)*

    • Office Use: STOP BANG Score (3-4 = Intermediate Risk, > 5 = High Risk):

    • GERD HQRL Scale 
    • Rows
    • How satisfied are you with your present reflux situation?*
    • Are you currently taking any medications for heartburn or GERD?*
    • Please select all medications that you are taking or have taken:

    • Patient Medication Information 
    • Rows
    • Patient Medical History 
    • Rows
    • Allergy Information 
    • Rows
    • Rows
    • Surgical History 
    • Rows
    • Family History 
    • Rows
    • Social History 
    • Marital Status
    • Tobacco Use*
    • Do you use alcohol?*
    • Do you use recreational drugs?
    • Have you ever been treated for narcotic dependency?
    • Do you have any children?
    • Do you have plans for children?
    • Review of Systems 

    • Please check all symptoms you currently experience, or have experienced in the past year:

    • General
    • HEENT
    • Gastrointestinal
    • Musculoskeletal
    • Neurological
    • Respiratory
    • Genitourinary
    • Psychological
    • Cardiovascular
    • Endocrine
    • Reproductive (Females)
    • Taking Birth Control? (Females)
    • Taking Hormone Replacements? (Females)
    • Health Screening 
    • Please select one:
    • Attestation 
    • Date*
       - -

    • Upon submission, you will receive an email confirmation. If not email confirmation is received, the form did not submit. Please make sure all fields with an asterisk are completed. You will also be shown a Thank you page as confirmation.

    • Should be Empty: