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 Cancelof
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?
Please check all conditions that may apply:

Bloating/belching/gasStomach cancerRectal BleedingHemorrhoidsColon cancerPolypsBlack stoolLiver problemsLeakage of StoolWeight lossHepatitis A, B or CHeartburn/indigestionIrritable bowelCrohn's/ Ulcerative colitisNauseaUlcersGallbladder diseaseVomitingPoor AppetitePancreas DiseaseDifficulty/pain swallowingHiatal HerniaColon cancer/polyp in familyAbdominal PainChest painAbnormal lab/RadiologyChange in bowel habitsHoarseness/coughAnemia/Low Blood CountDiarrheaIntestinal blockageOther:Constipation
REASON FOR VISIT: [If any item checked above, Please explain]
All Present And Past Medical Conditions. If left blank this signifies "no"

High Blood PressureHeart ProblemsDiabetesBleeding problemsCancerStrokeLung Problems
Other Illnesses:
LIST ALL PREVIOUS SURGERIES AND INCLUDE YEAR:
Marital Status

MarriedSingleDivorcedWidowed
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?

YesNo
If yes, how much?
Do you Drink Alcohol?

YesNo
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):
May not be given to anyone other than myself.
How may we send results, reminders, or important correspondence? Check one or all that apply. Please note these methods may not be secure.

Cell PhoneHome PhoneEmailMay leave detail voicemails
Signature*

Clear
Check any that apply: no selection signifies "no"

FeverFatigueWeaknessWeight loss/gainEyeglasses, contactsBlurred visionGlaucomaSore throatAllergies/sinus problemsHearing lossChest painSwollen feet/legsHeart murmurHeart rhythm problemsChronic coughCoughing up bloodShortness of breathAsthma/wheezingDifficulty urinatingUrinating more than twice a nightBlood in urineLeakage of urineTrouble starting or holding urineDifficulty with erectionJoint pain/swellingBack painMuscle painRashItchingSkin CancerHeadachesSeizuresStrokes/NumbnessMemory lossDepressionConfusionHeat/Cold IntoleranceExcessive Thirst/UrinationAnemiaBlood transfusion
Pharmacy Phone Number
Phone Number
Pharmacy Name/City
Pharmacy Name/City
Prescription History Consent

YesNo
Signature*

Clear
Signature*

Clear
Should be Empty: