New Patient Intake

New Patient Intake

Please complete this health history questionnaire to the best of your abilities. Dr Alexis Alexandridis will review your responses. Your Protected Health Information is secure on this intake form. If you do not have an appointment yet, please visit dralexissurgery.com and click on the "Schedule an Appointment" link.
Personal Information

Contact Info, Demographics, Emergency Contacts
Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Gender *

Female Male Non-binary Other
Email *
example@example.com
Phone Number *
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address, if different from home address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation
Employer
Insurance Information *
Plan Name **Please copy this information directly from your insurance card, or upload a picture below. Please be as specific as possible!**
ID number
Group Number
Effective Date
Medical Group Name, if applicable
Additional information from your insurance card:
Please include any additional information from your card here.
Secondary Insurance Information
Supplemental Plan Name. **Please be specific**
ID number
Group Number
Effective Date
Additional information from your insurance card:
Please include any additional information from your card here.
If you can, please upload a copy of your insurance cards, front and back:

A smartphone snapshot works fine!
Cancel of
Emergency Contact Name *

First Name Last Name
Relationship
Emergency Contact Phone Number
Primary Care Physician

First Name Last Name
Pharmacy
Where can Dr Alexis leave you a detailed message regarding results? *

Phone, as listed above E-mail, as listed above Neither Other, list here
Your Health Information

Past Medical and Surgical History
Why are you seeing Dr Alexis today? *
Body Measurements: *
Please list your Allergies:
Have you ever had or are you being treated for: *
Any other medical conditions?
Please list Operations or Major Procedures you have had:
Please list your Current Medications, including dosage. (If none, list NONE) *
Have you had a colonoscopy before?
If yes, when?
Results?
Women, are you?

Pre-menopausal Peri-menopausal Post-menopausal, natural Post-menopausal, surgical Other
Age at Menarche (first period)
Age at Menopause
Number of Pregnancies
Number of Births
Age at First Birth
Your Health Habits

Social History
Do you use Alcohol? *
If yes, how many drinks per WEEK
Do you use Tobacco? *
If yes, how many cigarettes (or equivalent) per DAY
Do you use Marijuana?
Additional Comments
Your Family Medical History

Has anyone in your family had cancer or a precancerous condition?

	Mother	Maternal Grandparent	Father	Paternal Grandparent	Sibling
Breast Cancer
Ovarian Cancer
Colorectal Cancer
Colorectal Polyps
Pancreatic Cancer
Other Cancers (please describe below)

What other diseases run in your family?
Click here if family history is UNKNOWN

Unknown family history
Review of Systems

Please check if you a CURRENTLY having trouble with any of the following: (Check all that apply)
General

Weight loss Fever/Chills Fatigue/Malaise Other
Eyes

Vision changes Discharge Eye pain Other
Ears, Nose, Throat

Earache Hearing loss Nosebleeds Sore Throat Other
Heart, Vascular

Chest pain Palpitations Fainting Painful breathing with exercise Pain in legs with exercise Swelling of arms/legs Other
Respiratory

Cough Trouble breathing Spitting up blood Wheezing Other
Gastrointestinal

Nausea or Vomiting Trouble swallowing, food getting "stuck" Diarrhea, more than 6 loose stools per day Constipation Blood in the stool, red Black stools Yellow skin, jaundice Change in bowel habits Other
Genitourinary

Painful urination Blood in the urine Abnormal menstrual bleeding Incontinence Pelvic pain Other
Musculoskeletal

Back pain Joint pain Joint swelling Muscle weakness Other
Skin

Rash Excessive dryness Suspicious lesion Other
Neurologic

Paralysis Numbness Vertigo Passing out Seizure Other
Psychiatric

Depression Anxiety Memory loss Suicidal ideation Other
Endocrine

Heat or cold intolerance Weight loss Excessive thrist, hunger Lethargy Other
Heme/Lymphatic

Abnormal bruising or bleeding Enlarged lymph nodes Blood clots Other
Allergy/Immunologic

Itching Hay fever HIV exposure Persistent infections Other
Thank you! Now, here is the fine print...

Please take a moment to review the policies below and indicate your acceptance. You do not need to print these forms. Your e-signature below indicates that you have READ the policies and ACCEPT the terms, including our "No-show"/cancellation FEES and billing/collections POLICIES. ***Ensure all items with a red asterisk are completed to complete your intake form.***
e-Signature *

Clear
Today's Date *

Month Day Year
Date
Should be Empty:

New Patient Intake

Personal Information

Your Health Information

Your Health Habits

Your Family Medical History

Review of Systems

Thank you! Now, here is the fine print...