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
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Other
Country
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
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Please Select
United States
Afghanistan
Albania
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Angola
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Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
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Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
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Egypt
El Salvador
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Falkland Islands
Faroe Islands
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Gabon
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Germany
Ghana
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Mayotte
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Micronesia
Moldova
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Mongolia
Montenegro
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Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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
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