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
Self
Spouse
Child
Other
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
Self
Spouse
Child
Other
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
*
Spouse
Parent
Sibling
Partner
Other
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
None
Appendectomy
Inguinal Herniorrhaphy
Adhesion Surgery
ERCP
Ulcer Surgery
Gallbladder Removal/Cholecystectomy
Weight Loss Surgery: Lap Band
Weight Loss Surgery: Gastric Bypass
Endoscopic Ultrasound/EUS
Hemorrhoidectomy
Anal Fissure
Liver Biopsy
Hernia Repair
Large Intestine/Colon Surgery
Small Bowel Capsule
Cardiovascular/Pulmonary
None
Carotid Stent Left
Aortic Aneurysm Repair
Coronary Artery Cath
Coronary Artery bypass surgery
Heart Valve Replacement
Pacemaker
Cardiac Ablation
Defibrillator
OB/GYN
None
Hysterectomy
Breast Removal/Mastectomy
Tubal Ligation
Ovary removed/Oophorectomy
Breast Aspiration/Biopsy
ENT
None
Tonsillectomy
Sinus Surgery
Endocrinology
None
Thyroidectomy
Thyroid Biopsy
Parathyroidectomy
Urology
None
Prostatectomy
Bladder Resection
Bladder Lift
Bladder Surgery
Prostate Surgery
Nephrectomy
Orthopedic and Neurological
None
Knee Surgery Right
Knee Surgery Left
Hip Replacement Right
Hip Replacement Left
Shoulder Surgery
Hand Surgery
Craniotomy Spinal Surgery
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
Submit
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