GI Medical History

GI History Registration

Austin Medical Group, PLLC.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email
example@example.com
Primary Insurance Information

Insurance Policy Name

Street Address

City State / Province

Postal / Zip Code
Policy Holder Date of Birth

Month Day Year
Date
Policy Number
Group Number
Relationship to Policy Holder
Secondary Insurance Information

Insurance Policy Name

Street Address

City State / Province

Postal / Zip Code
Policy Holder Date of Birth

Month Day Year
Date
Policy Number
Group Number
Relationship to Policy Holder
Pharmacy Information *

Pharmacy Name

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Emergency Contact Information *

Name of Emergency Contact

Street Address

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Relationship to Patient *
Reason for Visit *
Allergies/Reaction (Please include medications also) *
Current Medications
Include ALL prescriptions, vitamins/supplements, over-the-counter and herbals
Immunizations

None Hep A Hep B
Hep A Date

Month Day Year
Date
Hep B Date

Month Day Year
Date
Diagnostic Tests/Studies

None In the past 12 months I have had X-rays In the past 12 months I have had lab test Colonoscopy EGD-Esophagogastroduodenoscopy
Past Medical History (Select all that apply) *

Heart Disease Stroke Hepatitis/Liver Disease Asthma/Lung Disease Arthritis High Cholesterol Migraines GI Disease Kidney Disease Back/Spine Disorder High Blood Pressure Seizures/Head injury Peptic Ulcer Glaucoma/Vision Problems Seasonal Allergies Diabetes Thyroid Disease Depression/Anxiety Other NONE
Family History :

Colon Polyp Colon Cancer

Please select any family medical problems

Mother

Father

Sister

Brother

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Deceased

Stroke

Blood Clot

Cancer (Type)

Heart Problems

Diabetes

High Blood Pressure

High Cholesterol

Lung Problems

Thyroid Problems

Other

NO KNOWN HISTORY

Previous Procedures
Gastrointestinal
Cardiovascular/Pulmonary
OB/GYN
ENT
Endocrinology
Urology
Orthopedic and Neurological
Other Surgery not listed
Occupation *
Do you currently use tobacco? *

YES NO
If yes, age you started using tobacco?
Have you ever used tobacco? *

YES NO
If yes, please specify stop date

Month Day Year
Date
Do you drink alcohol? *

YES NO
Do you consume caffeine? *

YES NO
If yes, how much and how often?
Do you currently use recreational drugs? *

YES NO
If yes, which recreational drugs?
Have you ever used recreational drugs? *

YES NO
If yes, please specify stop date

Month Day Year
Date
Are you sexually active? *

YES NO
If yes, please select all that apply:

One partner Multiple partners Female partners Male partners
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GI History Registration