TEANECK GASTRO RECALL QUESTIONNAIRE

TEANECK GASTRO RECALL QUESTIONNAIRE

Drs. Schmidt, Micale, Palance, Lin & Welinsky
Todays Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PLEASE ENTER YOUR FULL NAME

First NameLast Name
Patient Date of Birth

MonthDayYear
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BEST PHONE NUMBER TO REACH YOU
Please enter a valid phone number.Format: (000) 000-0000.
ALTERNATIVE PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance
Insurance ID Number
2ND Insurance
2ND Insurance ID Number
Pharmacy Name
Pharmacy City
Pharmacy Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Your Current Weight in pounds
Your Current Height in inches
Did you receive the covid vaccine?
Do you take Ozempic, Wegovy, Mounjaro, Rybelsus, Trulicity, Saxenda, Byetta, Bydureon BCise, Victoza or any other GLP-1 drugs for weight loss or diabetes?
How often do you take it?
Are you on any anticoagulants (blood thinners) like Coumadin, Warfarin, Plavix, Lovenox, Ticlid, Aggrenox, Trental, Brilante, Pradaxa, Xarelto or Effient?
Name of Anticoagulant Drug
Dose
Frequency taken
If yes, who prescribed it? (name and phone number)
Do you have any blood clotting disorders? (bleeding or clotting issues)
Do you take aspirin on a daily basis?
If yes, which strength do you take?
If yes, who prescribed it? (name and phone number)
Are you diabetic?
If yes, what diabetic medications do you take? (name)
diabetic medication dose
frequency that you take diabetic medications (once a day, twice a day, etc.)
2nd diabetic medications (name)
2nd diabetic medication dose
frequency that you take diabetic medications (once a day, twice a day, etc.)
Do you take your diabetic medications in the
Do you take a diuretic or water pill?
If yes, what is the name of the water pill?
Dose of Water Pill
Frequency taken (once a day, twice a day)
What time of day do you take your water pill?
Do you take blood pressure or cardiac medications?
If yes, what blood pressure or cardiac medication do you take (name and strength)?
Dose of Blood pressure medication
Frequency that you take Blood pressure medications (once a day, twice a day)
what time of day do you take your blood pressure medication?
Who prescribed this medication? Please include name and phone number.
Do you take iron pills or vitamins that contain iron?
Do you take antibiotics before going to a dentist?
What antibiotic do you take (name, dose and frequency)
Are you allergic to any antibiotics?
If yes, what antibiotic are you allergic to?
Have you been on antibiotics in the last month?
If yes, for what condition did you take antibiotics?
What antibiotic were you taking?
Do you have any STENTS or have you had cardiac bypass surgery?
Have you had rheumatic fever or heart valve replacement?
Do you have congestive heart failure?
Do you have an implantable defibrillator?
Do you have a pacemaker?
Have you had an echocardiogram, stress test, nuclear stress test, cardiac catheterization or holter monitor in the last 5 - 10 years?
If so, When
Why?
Do you see a cardiologist?
If you do see a cardiologist, Why?
Have you had a hip, knee or joint replacement in the last six months?
Are you a renal dialysis patient?
Do you have a history of hepatitis or cirrhosis?
Do you have lung disease, asthma, COPD (chronic obstructive pulmonary disease) or sleep apnea?
Do you use supplemental oxygen?
Are you over the age of 75?
Since your last procedure, have you had a heart attack or stroke?
Have you ever had a hard time cleaning out for your colonoscopy?
Do you have ulcerative colitis or Crohn's Disease?
Patient Signature
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