New Patient Intake Form

Patient Intake Form (Secure)

Brian F. Sweeney, Jr., MD

(907)562-2928

First Name

Middle Name

Last Name

Date field

Referring/ Primary Care Provider

Returning Patient

Yes No

Gender

Male Female

Date of Birth

Marital Status

Social Security Number

Email field

Address

City

Zip code

Cell Phone

Home Phone

Work Phone

Employer

Spouse

Spouse Date of Birth

Ethnicity

Hispanic

Pacific Islander

White Non-Hispanic

Black/African American

Other/ Unknown

Decline

Primary Insurance Carrier

Insured

DOB

Insurance ID#

Insurance Group Number

Secodary Insurance Carrier

Insured

DOB

Insurance ID#

Insurance Group Number

Reason for Visit

Past Medical History

Past Surgical History

Medications (please include doses and any OTC medications)

Allergies

Are you on any blood thinning medications (please list)

Do you take any OTC pain medications

Yes

Please tell us if you smoke tobacco or have in the past and for how long

Please tell us if you drink alcohol and how much

Do you smoke or use cannabis is any way? How much?

Do you have a family history of any of the following?

Colon cancer

Colon polyps

Liver disease

Ulcerative Colitis

Crohn's Disease

Pancreatitis

Heart Disease

Please expand on family members with above and age they were diagnosed if known

Do you have any of the following gastroenterology symptoms

Abdominal pain

Trouble swallowing

Nausea

Vomiting

Blood in the Stool

Heartburn

Jaundice

Constipation

Diarrhea

Anything else we need to know?

Please also send us a copy of a photo ID and insurance card back and front. We need this to be able to bill your insurance. We will also be sending you an e-mail with documents for electronic signature if we have not already. Thank you for choosing us for you Gastroenterology needs.

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