Dr. Alam - Gastroenterology Patient ePaperwork

Today's Date

Patient Name

Date of Birth

Type Birthday

EMAIL:

example@example.com

CELL PHONE:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please Upload a Photo of ID and Insurance Cards: IF YOU CANNOT DO THIS STEP, YOU MUST TEXT A PHOTO TO 936-321-0000 OR BRING THEM BY OUR OFFICE

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A photo of medication list/allergies can be uploaded here if you do not want to type them out.

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Medication/Allergy List

ALLERGIES:

Current Medications Including over the counter. Name, strength, frequency

May also upload a photo of your list below instead of typing each medication. To do so type "see list" in above box.

Primary Insurance Name

May be left blank only if a photo of your card is provided above

Primary Insurance ID/Policy # and Group #

May be left blank only if a photo of your card is provided above

If applicable- Secondary Insurance Name

May be left blank only if a photo of your card is provided above

Secondary Insurance ID and Group

NAME OF REFERRING PHYSICAN:

Name of Primary Care Physician:

Current Weight and Height

Have you had a Colonoscopy before? If yes, when and by which MD?

Have you had and EGD (upper endoscopy) before? If yes, when and by which MD?

Do you take any GLP-1 Medications? (Ozempic, Wegovy, Mounjaro, Semaglutide, etc)

Yes or No, please specify.

Please check all conditions that may apply:

REASON FOR VISIT: [If any item checked above, Please explain]

All Present And Past Medical Conditions. If left blank this signifies "no"

Other Illnesses:

LIST ALL PREVIOUS SURGERIES AND INCLUDE YEAR:

Marital Status

Family History (List any medical conditions and age) Mother:

Family History (List any medical conditions and age) Siblings:

Family History (List any medical conditions and age) Children:

Family History (List any medical conditions and age) Father:

Any family history of colon cancer, polyps or liver disease?

Occupation:

Do you Smoke?

If yes, how much?

Do you Drink Alcohol?

If yes, how much?

I give my authorization to release my protected health information including results of labs, radiology, procedures, etc to the following designated representative(s):

How may we send results, reminders, or important correspondence? Check one or all that apply. Please note these methods may not be secure.

Signature

Check any that apply: no selection signifies "no"

Pharmacy Phone Number

Phone Number

Pharmacy Name/City

Prescription History Consent

Signature

Signature